Incidence of Diabetes mellitus in older adults

What Is The Effect Of Specific Diseases Morbidity Clusters?

The number of elderly or geriatric patients of diabetes in Australia and the world are growing due to higher life expectancy, increase in population of the aged and lifestyles that are sedentary and diets that are nutrition dense. Of particular concern is the high prevalence of diabetes among the Aboriginals and Torres Strait Islanders in Australia. Their socio-economic status and lower levels of awareness about lifestyle choices could have put them at a greater risk. The risk of complications associated with diabetes and the presence of co-morbidities in the geriatric population makes it important for high quality of care delivery. The diagnosis of diabetes and related complications among the elderly impacts their well being and if associated with cognitive decline their ability to self-manage medication, diet and exercise regimen is affected. The delivery of care through government programs in Australia is available but the growing numbers of patients poses a challenge. Nursing staff is trained in dealing with in-patients at hospitals and many of them are trained as diabetes educators. The role played by the educators can help patients and their families to cope with the stress of dealing with diabetes. Nurses also help in the transition of patients from the hospital and ensure that after the discharge the patient is able to receive medication.

The incidence of Diabetes Mellitus among those aged 65 and above has seen an increase all over the world and in Australia more than half a million people in this age group suffer from diabetes (AIHW, 2017). 10.8 million people among the aged in the US suffer from diabetes as detected by the fasting blood levels and the HbA1c (Caspersen, Thomas, Boseman, Beckles, & Albright, 2012). In most of the cases patients are type 2 diabetics. Diabetes is a group of diseases that results due to high blood glucose levels that could be n outcome of reduced insulin production by the pancreas or defects in insulin action, at times both the reasons are attributed to the condition (CDC, 2011). The prevalence of diabetes among the Aboriginal and Torres Strait Islanders is 38% as compared to the 12% rate of prevalence among the non-indigenous Australian elderly population (AIHW, diabetes, 2017). The risk of complications due to diabetes, such as, foot complications is more common among the Aboriginals and Torres Strait Islander people (West, Chuter, Munteanu, & Hawke, 2017). Aboriginals are 4.3 times more likely to be hospitalised due to diabetes related complications than the general population (Gibson, 2017). Several complications are associated with diabetes when blood sugar levels are uncontrolled. Cardiovascular disease, kidney disease, retinopathy, peripheral neuropathy, depression, anxiety and distress are major risks. However, well managed blood glucose levels can help patients stay safe from complications.

Impacts on the individual

The impact of a diabetes diagnosis on the patient can be enormous. The patient may feel overwhelmed with the possibility of complications, frustrated with having to make lifestyle changes and may feel lonely. Some patients may be able to cope better than others, but those with weaker coping mechanisms may feel a greater impact. A newly diagnosed patient may suffer from mental healthcare issues, such as, depression and anxiety. There may be distress due to the need to constantly watch one’s diet, remember to take medication and include some form of physical exercise. Periodic checks for glycosylated hemoglobin, systolic blood pressure and blood lipids require the patient to be engaged in self-care all the time. The economic burden of the medicines and tests also impact the patient. Health related quality of life does not remain as it was before the diagnosis of diabetes (Leach, et al., 2013). The annual direct costs of people who have complications are more than double the cost of those living without complications and can surge to $9600 from $3500 (Health.gov.au, 2015).  The challenge of living with diabetes is significant for the elderly because of episodes of hypoglycemia, co-morbidities, poor food intake, recent hospitalisation may cause reduced independence (Jafari & Britton, 2016). There are a large number of elderly diabetics who face disability due to loss of vision or due to amputation caused by prolonged hyperglycemia. These are complications that are preventable through proper management of blood sugar levels (Wong, et al., 2016). Of particular concern is the impact of diabetes on the cognitive function of the brain. Self care and management of the disease requires that even in old age the patient should be able to make informed choices and remember to take medication as per schedule. The decline in cognitive function can increase the dependence of the elderly on the carers. Mild cognitive decline may advance to dementia with advancing age. Issues with maintaining glycemia, inflammation, vascular and metabolic impacts of diabetes can affect the brain in those with long-standing diabetes and the newly diagnosed patients. A 2.0 to 3.4 fold increase in the risk of vascular dementia has been reported by studies carried out on elderly diabetes patients (Samaras & Sachdev, 2012). Ongoing treatment of chronic conditions due to diabetes can incur out of pocket expenditure for the elderly and impact their household budgets negatively, leaving less availability of money for other expenses (Islam, Yen, Valderas, & McRae, 2014).

Impacts on the health system of Australia

The impact of diabetes among the elderly and the costs incurred in treatment of the mostly preventable complications are enormous even for a high income country like Australia. The economic burden not only impacts the households of diabetic patients but the healthcare system of Australia is also affected. With passing time the cost of illness has increased. In situations where the elderly are not able self care, an at home carer, residential aged care or institutionalised care may be required. There are times when the elderly need help to check for the accuracy of blood glucose tests or whether their instruments are functioning optimally, whether the meaning they decipher from food labels is correct, for example, should they drink fruit juice that has no added sugar. The Department of Health of the Australian government has the National diabetes Service Scheme through which registered patients can receive subsidies on medicines, insulin, blood glucose strips and other requirements for keeping the hyperglycemia and hypoglycemia under check. Government spending on the treatment of diabetes monitoring and treatment is therefore substantial.

The causes for diabetes among the elderly could be several. Some may have suffered from the condition since a younger age while most could have become resistant to insulin or have low insulin secretion from the pancreas post the age of 65 years. In both cases the sedentary life styles and nutrient dense western food consumption could be the cause. Among the Aboriginals and Torres Strait Islanders, the elderly are particularly prone to diabetes. Poor diet that is devoid of the recommended servings of fresh fruit and vegetables is an important reason. For members of the community who live in remote locations and do not have access to fresh produce. Even those who live in non-remote areas and have access to fresh produce may make unhealthy choices and consume high amounts of sugar in the form of sweetened beverages and cakes, pastries. Only 15% of the population consumes the recommended five serves a day. Obesity and high body mass index among the indigenous people make them more likely to suffer from diabetes (Healthinfonet, 2013). They are four times more likely than non-indigenous Australians to suffer from diabetes (Diabetesaustralia). Consumption of food rich in fats, sugar and salt is often considered to increase the risk of getting diabetes. The diabetesaustralia.com.au website has several resources on educating the indigenous people about the awareness to detect and diagnose diabetes at an early stage, before complications can set in. Differences in body mass index and the level of awareness and education have made the Aboriginals and Torres Strait Islanders more prone to diabetes. Their low socio-economic status makes it more likely that they suffer from diabetes due to maintenance of a poor lifestyle. Removal from families has caused stress that could be a contributing factor (Reeve, Church, Haas, Bradford, & Viney, 2014).

Role of nurse in assessment and prevention strategies

Nursing practitioners can play an important role in the assessment and prevention strategies. A diabetes nursing practitioner can order blood tests, help the patients and their families to understand self-management, adjust insulin doses, and even prescribe medication for managing the blood sugar levels in a better manner. Nurses can help in making the patient aware about the complications associated with poorly controlled diabetes. They can also raise awareness among people who are pre-diabetic and have higher values of fasting blood glucose, so that they can make lifestyle modifications and postpone the onset age of diabetes as far as possible. Since they are in constant contact with patients they can help in communicating case specific information to the physician. Specific recommendations and reminders about diet, exercise can be given to the patient. The need to check blood sugar levels at different times of the day, and tests for HBA1c, lipids and renal function are important considerations when caring for an elderly diabetes patient. Elderly patients living in the community or residential aged care can receive help from a diabetes nurse who can assess their level of confidence in managing diabetes and reducing the chances of complications (Murfet, 2014). The set of problems faced by elderly patients include fraility, propensity to fall and cognitive impairment. An assessment of the patient with regard to whether they can return to the pre-hospitalisation levels of self-care is an important step to be carried out by the nurse at the time of discharge. The patient’s hydration status and episodes of hypoglycemia during the stay at the hospital are important and patient’s home care-giver or the patient should be instructed about how to deal with similar situations upon discharge. The nurse needs to ensure that transition from the hospital to home environment occurs smoothly and the patient’s co-morbidities are taken care of. Many elderly patients have multiple medications and polypharmacy (the use of 5-9 drugs) is more likely. It is important to check whether an antibiotic leads to hypoglycemia in the patients or if there is the risk of other drug interactions (Runganga, Peel, & Hubbard, 2014). Direct communication with family members about the plan of the treatment and the importance of maintaining blood sugar levels within the normal range are important aspects of transition from in-patient to home setting. Several challenges are presented by elderly diabetes patients. The presence of co-morbidities makes the task of the nurse more complicated. Communication of the nurse with the patient and the family is important in trying to ensure a safe transition from an inpatient to home or residential care. A good reference for nurses is the Diabetes Management Journal that is published by Diabetes Australia. It provides evidence based information and the latest guidelines released by the National Health and Medical Research Program (NHMRC). It is a good source to learn about the newly developed products that help in management of diabetes. The best practices in the management of diabetes are also published in the journal regularly (Diabetesaustralia.com.au).

Conclusion

The care of elderly patients with diabetes is an important public health concern because of the growing number of patients, some who have been newly diagnosed and some have longstanding disease. With increasing age the risk of complications increases substantially and good glycemic control through medication and follow up with blood glucose testing, testing for blood pressure, lipids and renal testing assume importance. The high occurrence of diabetes mellitus among the Aboriginals and Torres Strait Islanders has been understood to result from their low socio-economic status and low education levels. The stress of broken families has taken its toll on them and they are unable to make healthy life style choices. The impact of diabetes and the resulting complications on the elderly takes a toll on their overall well being. They may suffer from cardiovascular disease, chronic kidney disease, retinopathy, microvascular and macrovascular problems. The economic impact on the family is an added stressor because even if the government provides subsidies on glucose monitors, glucose strips and medication, out of the pocket expenditure on the treatment strains the family’s financial resources. The high cost of treatment is a burden on the national exchequer. Nurse educators trained in helping patients to self manage the disease and to provide smooth transitions to hospitalised patients have a major role to play in assessing the ability of the elderly patients to self manage their medication, diet requirements depending on their levels of cognition.

References

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