NRS410V Pathophisiology

About 30 percent of the age above 65 years in the US are suffering from diabetes mellitus. This is because aging is driver to diabetes. Mostly diabetes is described on the basis of its consequences on the patient (mostly the working class), among the older generation it is associated with high mortality rate and low body activity. The elderly people suffering from diabetes mellitus are at a high risk of contracting the CVDs and other chronic infections. Diabetes mellitus is expected to increase as life expectancy and the aging generation increase. Apart from diabetes, CVDs and geriatric syndromes are rising complications among the older people. Both in the younger and elderly patients, treatment of diabetes involves hyperglycemia and risk factors. The treatment of diabetes should be individualized and take in to consideration functional limitations and comorbid diseases. Hypotension, hypoglycemia and drug interactions should be highly avoided in the treatment of elderly diabetes patients.

According to Dorrington & Bowdish (2013), the innate and adaptive changes in immunity that occur as one ages are associated with the increased infections in the elderly. The leukocyte produced on the bone marrow is biased towards the myeloid cells to the neglect of naïve lymphocytes (Montgomery & Shaw, 2015). The reduced T cell and thymus outputs are thought to be a cause of the reduced novel infections among the elderly (Geiger, de Haan and Florian, 2013). The changes in B cells also contribute to the reduced response to infections among the old as it alters the de novo antibody response (Aberle, Stiasny, Kundi and Heinz, 2012). This raises the alarm for the clinicians and nurses to develop sensitivity towards the needs of this generation. A study carried out in the United States between 1995 and 2004 shows that type 2 diabetes (T2DM) has increased from 16 percent to 23 percent (Zhang, Decker, Luo, Geiss, Pearson, Saaddine, Gregg and Albright, 2010). For the current generation, between 22 percent and 33 percent of the people above 65 years of age are diagnosed with diabetes. It is also predicted that this number would increase by 4.5 times before 2050 (Kirkman, Briscoe, Clark, Florez and Halter, 2012). This paper aims at discussing type 2 diabetes among the elderly, its causes, effects, diagnosis, treatment and management.

As age progresses, there is increased intolerance to glucose leading to the more diabetes cases. Reduced B cell compensating capacity for the elderly generation leads to insulin resistance and occurs as a postprandial hyperglycaemia. Diabetes mellitus prevalence increase with increase with age and the elderly could be incidentally diagnosed after 65 years, at the middle age of later. Different clinical and demographic requirements for the treatment of diabetes mellitus for different ages causes confusion in the health care setting. Use of less insulin and lower A1C are characteristic features of age related diabetes especially among the non-Hispanic whites (Yakaryilmaz & Ozturk, 2017). Selvin, Coresh and Brancati (2006) think that there is no difference between diabetes mellitus and CVDs prevalence among the aging generation. The older people above 75 years old are more vulnerable to contracting T2DM and other chronic infections as compared to the lower generation.

Overweight, lack of physical activity and obesity are the common causes of T2DM contributing to about 95 percent of diagnosed diabetes cases in the US (WebMD, 2018). In a healthy person, the pancreas secretes insulin that helps the body digest and use sugar in the food ingested. This is not the case for a diabetic person, it is either the pancreas does not secrete insulin, produces it in little amounts or the body has an impaired response to insulin (insulin resistance). For people with T2DM, unlike those with T1DM, their pancreas produces insulin either in small amounts or their bodies do not recognize the insulin secreted or does not use it appropriately. Glucose in the blood cannot move into body cells but it accumulate in the blood streams. The body cells are unable to function as required because they do not get enough glucose.

According to Meneilly and Tessier (2001), there are different risk factors contributing for the prevalence of T2DM in the older generation. In ethnic groups, genetic factors are the leading risk factors. Changes in carbohydrate metabolism in the aged, in combination with genetic factors can be used to explain the increase in type 2 diabetes among the old. According to the NIDDK (2018), life style and obesity are among the leading risk factors for diabetes. People who eat diets with high fat concentration, low complex carbohydrates and are not are not active, are most likely to contract this disease as they approach the old age. Although uncertain, high levels of testosterone in women and low levels in men appears to be among the risk factors for diabetes for the old. A research that aimed at evaluating glucose metabolism in the young generation having type 2 diabetes indicated that there were some abnormal metabolic characteristics in these patients. They showed high fasting hepatic glucose secretion, insulin resistance and defects in glucose induced insulin secretion. The study also assessed obese older patients which showed that hepatic glucose secretion was within the required range unlike in the younger generation. The study also showed that the elderly have a condition found to be between T1DM and T2DM.

In the US, studies show that 8 to 45 percent of diagnosed diabetes cases among the youth is T2DM. Type two diabetes cases in Japan has outnumbered type 1 diabetes case, with statistic showing a double increase from 7.3 percent in 1980 to 13.9 percent in 1995 (Alberti, Zimmet, Shaw, Bloomgardden, Kaufman and Silink, 2004). According to Lascar, Brown, Pattison, Barnett, Bailey and Bellary (2017), just like in the older generation, prevalence of type 2 diabetes among the youths is as a result of obesity, sedentary life style and family history. Its onset is associated with increased chronic complications and disease exposure. According to Lascar et al. (2017), type 2 diabetes phenotype among the young people is more aggressive, which causes premature development in the disease complications, affecting the young people’s quality of life hence making the disease a world public health pandemic. According to Kesavachandran, Bihari and Muthur (2012), increased type 2 diabetes in the young generation in the society is a consequence of obesity. They think that the community and the educational system have failed in educating children and parents on the risk factors of T2DM and the primary prevention. According to Alberti et al. (2004), girls, according to research, are more likely to contract T2DM, with 1.7 times more than their male age mates, though the reason behind this is unknown. There is a need for the government and any stakeholders to educate the young people on diabetes if the world has to control this disease. As the prevalence of this disease increases among the youth, there is a likelihood of increased complications associated with type 2 diabetes such as retinopathy, hypertension and cardiovascular diseases (Doeke, Hajare and Saoji, 2002).

According to Yakaryilmaz and Ozturk (2017) just like in the young people, the treatment of diabetes involves hyperglycemia and risk factors. Too much drugs, hypotension and hypoglycemia should be highly avoided in treatment of diabetes for the elderly. Management and treatment of diabetes should be based on the predicted life span and the health status of the patient. The elderly need counseling on lifestyle changes. They also need advice on their diets so that they consume low fat diets. Medical therapy for the elderly diabetic patients, lifestyle changes and metformin are the primary recommendations for treatment. Patients with comorbid need 3 to 6 months monitoring before starting metformin therapy. Insulin releasing drugs such as sulfonylureas and meglitinides are also recommended (Holstein, Hammer, Hahn, Kulamadayil and Kovacs, 2010). Alpha glucosidase inhibitors are prescribed to inhibit alpha glucosidase enzyme used in the absorption of carbohydrates. According to Leontis (2018), the best ways to prevent this disease is maintaining a healthy body weight, increase body activity and eating healthy diet. There has been a slow success in controlling this disease due to little knowledge on its risk factors and prevention methods especially in the rural areas. According to Horton (2008), the management of diabetes in the elderly is facing challenges due to increase in functionality disability and comorbid diseases. Treatment of type 2 diabetes has to consider both micro and macro vascular complications as a result of old age and the infection. This makes the treatment and management of diabetes complex. The diagnosis also has challenges as most of the elderly are not correctly diagnosed for this condition due to factors like natural increase of renal threshold for glucose as age advances. Symptoms such as blurred vision, polyuria and fatigue are common in the elderly as therefore cannot be used in the as a symptom for diabetes.

References

Aberle, J. H., Stiasny, K., Kundi, M. and Heinz, F. X. (2012). Mechanistic Insight into the Impairment of Memory B Cells and Antibody Production in the Elderly. The Springer, Vol. 35, No. 2, pp. 371-381. Doi: https://doi.org/10.1007/s11357-011-9371-9

Alberti, G., Zimmet, P., Shaw, J., Bloomgarden, Z., Kaufman, F. and Silink, M. (2004). Type 2 Diabetes in the Young: the Evolving Epidemic. The Voice of Women in Diabetes, Vol. 27, No. 7, pp. 1798-1811. Doi: 10.2337/diacare.27.7.1798.

Deoke A, Hajare S, Saoji A. (2012). Prevalence of overweight in high school students with special reference to cardiovascular efficiency. Glob J Health Sci. 4:147–52.

Dorrington, M. G. and Bowdish, D. M (2013). Immunosenescence and novel vaccination strategies for the elderly.  Front Immunol. 4:171.

Geiger H., de Haan, G. and Florian M. C. (2013). The ageing haematopoietic stem cell compartment.  Nat Rev Immunol 13:376-389.

Holstein A., Hammer C, Hahn M, Kulamadayil N. S and Kovacs P. (2010). Severe sulfonylurea-induced hypoglycemia: a problem of uncritical prescription and deficiencies of diabetes care in geriatric patients. Expert Opin Drug Saf. 9:675–681

Horton, E. S. (2008). Challenges in the Management of Type 2 Diabetes in the Elderly. US Endocrinology, Vol. 4, No. 1, pp. 47-50. Doi: 10.17925/USE.2008.04.01.47

Kesavachandran CN, Bihari V, Mathur N. (2012). The normal range of body mass index with high body fat percentage among male residents of Lucknow city in North India. Journal Family Medicine Primary Care, Vol. 135, pp. 72–77.

Kirman, S., Briscoe, V. J., Clark, N., Florez, H., Haas, L. B., Halter, J. B., Haung, E. S., Korytkowski, M. T., Munshi, M. N., Odegard, P. S., Pratley, R. E. and Swift, C. S. (2012). Diabetes in Older Adults. Diabetes Care, Vol. 35, No. 12, pp. 2650-2664. Doi: 10.2337/dc12-1801

Lascar, N., Brown, J., Pattison, H., Barnett, A. H., Bailey, C. J. and Bellary, S. (2017). Type 2 Diabetes in Adolescents and Young Adults. The Lancet, Vol. 6, No. 1, pp. 69-80. Doi: https://doi.org/10.1016/S2213-8587(17)30186-9

Leontis, L. M. (2018). Type 2 Diabetes Prevention. Retrieved from: https://www.endocrineweb.com/conditions/type-2-diabetes/type-2-diabetes-prevention

Montgomery R. R. and Shaw, A. (2015).  Paradoxical changes in innate immunity in aging:  recent progress and new directions. J Leukocyte Biol.  pii:jlb.5MR0315-104R.  [Epub  ahead  of  print].

Meneilly, G. S and Tessier, D. (2001). Diabetes in Elderly Adults. The Journals of Gerontology: Series A, Vol. 56, No. 1, pp. M5–M13, https://doi.org/10.1093/gerona/56.1.M5

Selvin E, Coresh J. and Brancati F. L. (2006). The burden and treatment of diabetes in elderly individuals in the US. Diabetes Care. 29:2415–2419

The National Institute of Diabetes and Digestive and Kidney Diseases. (2018). Prevention of Type 2 Diabetes. Retrieved from: https://www.niddk.nih.gov/health-information/diabetes/overview/preventing-type-2-diabetes

WebMD. (2018). Causes of type 2 diabetes. Retrieved from: https://www.webmd.com/diabetes/diabetes-causes#1

Yakary?lmaz, F. D., & Öztürk, Z. A. (2017). Treatment of type 2 diabetes mellitus in the elderly. World Journal of Diabetes, 8(6), 278–285. https://doi.org/10.4239/wjd.v8.i6.278

Zhang X., Decker F. H., Luo, H., Geiss, L. S., Pearson, W. S., Saaddine, J. B., Gregg, E. W, and Albright, A. (2010). Trends in the prevalence and comorbidities of diabetes mellitus in nursing home residents in the United States: 1995-2004. J Am Geriatr Soc. 58:724–73