Glucose Effectiveness Or Noninsulinmediated Glucose Uptake

It has been recognized for decades that insulin is an important hormone involved in the uptake of glucose into cells. Recently it has been demonstrated that glucose can stimulate its own uptake in the absence of insulin (Best et al 1996). This is known as 'glucose effectiveness' or non-insulin-mediated glucose uptake (NIMGU). Under fasting conditions, approximately 70 of glucose uptake occurs via glucose effectiveness, primarily in the central nervous system. After a meal, approximately 50 of...

Screening For Diabetic Complications

Currently, many elderly people already have chronic complications of diabetes which may be asymptomatic at diagnosis. These should be screened systematically by history, examination and appropriate laboratory investigations. Table 3.5 presents some guidelines for initial examination and appropriate laboratory investigations for chronic diabetic complications. Symptoms of sensory, motor and autonomic neuropathy should be documented at the time of diagnosis of diabetes and reassessed at least...

Meglitinides

Meglitinides belong to a novel group of insulinotropic agents known as the non-sulfonylurea insulin secreta-gogues (Malaisse 1995). Repaglinide, a benzoic acid derivative, is one of the meglitinide analogues that recently became available. Like sulfonylureas, the insulinotropic effect is mediated through the ATP-regu-lated potassium channels but via different binding sites on the beta-cells (Balfour and Faulds 1998 Fuhlendorff 1998). After oral administration, repaglinide is quickly absorbed...

Age group years

Figure 8.3 Standardized mortality ratios (SMRs) to the general population for all-cause mortality, according to sex and age in the cohort of Type 2 diabetic patients of Verona 8.2). Thus, healthcare planners should bear in mind that even a small percentage reduction in the mortality rate in this age range can eventually prolong the survival of many patients (Fullet et al 1983 Muggeo et al 1995a Sinclair, Robert and Croxson 1997). The age modulation of the excess mortality due to diabetes could...

Aims Of Diabetes Care In Institutional Settings

Residents with diabetes in care homes should receive a level of comprehensive diabetes care commensurate with their needs. This should be on an equitable basis with those people with diabetes who do not live in an institutional setting. The two most important objectives are 1. To maintain the highest degree of quality of life and well-being without subjecting residents to unnecessary and inappropriate medical and therapeutic interventions. 2. To provide sufficient support and opportunity to...

Glucagonlike Peptide

GLP-1 is a very potent insulinotropic peptide hormone secreted by the L-cells of the intestinal mucosa in the lower gut Holst 1994 0rskov 1992 . The in- sulinotropic effect is mediated at the level of the L-cells through a stimulation of adenylate cyclase and protein kinase A activity Drucker et al 1987 . Unlike sulfonylurea agents, GLP-1 has no hypoglycemic effect in the absence of glucose Goke et al 1993 . Its secretion increases in response to unabsorbed nutrient within the intestinal lumen....

References

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...

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...

Appointments and Recall

Old Age Medical 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

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

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...

Predictors Of Mortality

Verona Diabetes Study

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

Kcl Infusion

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...

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...

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

Diabetes Rates 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...

Counterregulation

Glucose 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...

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...

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...

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...

Glucose Counterregulation

Numerous studies have found that elderly patients with diabetes, when compared with younger patients, have an increased frequency of severe or fatal hypoglycemia Stepka, Rogala and Czyzyk 1993 . A number of studies have evaluated glucose counter-regulation in elderly subjects to try to determine the cause of the increased frequency of hypoglycemia, and some important observations have emerged. Many elderly patients with diabetes have not been educated about the warning symptoms of hypoglycemia...

Counterregulatory Mechanisms

Because many physiological processes alter with advancing age in humans, it is important to determine whether the ageing process per se may affect the nature and efficacy of the glucose counter-regulatory response to hypoglycaemia. In non-diabetic elderly subjects, a study of the counter-regulatory hormonal responses to hypoglycaemia induced by an intravenous infusion of insulin suggested that diminished secretion of growth hormone and cortisol is a feature of advanced age Marker, Cryer and...

The Choice Of An Antidiabetic Agent In Elderly People

In general, the management of Type 2 diabetes should be individualized and tailored to the clinical status of the individual, coexistent diseases, bodyweight, goals of therapy, expectations, involvement in care, functional impairment, ease of administration, side-effect profile, cost of therapy, baseline blood sugar and the urgency of blood sugar normalization. Although difficult to generalize when considering all these parameters, some guidelines can be suggested based on blood sugar levels...

DKA Risk Factors and Management

Type 1 diabetes does occur in elderly people Sturrock et al 1995 and the age-specific incidence is the same from 30 to 80 years of age Molbak et al 1994 . It is relatively uncommon as a de novo presentation, and can catch the physician out. It may present as DKA, but may also present as an outpatient appearing very similar to a subject with Type 2 diabetes in whom the plasma glucose levels never really lower in response to rapidly escalating doses of oral agents. DKA does occur in Type 2...

Stacpoole Pw Wright Ec 1994 47-52

Adrogue HJ, Barrero J, Eknoyan G 1989 Salutary effects of modest fluid replacement in the treatment of adults with diabetic ketoacidosis JAMA 262, 2108-2113. Alberti KGGM 1989 Diabetic emergencies. British Medical Bulletin, 45, 242-263. Asplund K, Wilholm B-E, Lithner F 1983 Glibenclamide-asso-ciated hypoglycaemia a report on 57 cases Diabetologia, 24, 412-417. Asplund K, Wiholm BE, Lundman B 1991 Severe hypoglycaemia during treatment with glipizide. Diabetic Medicine, 8, 726-731. Atkin SH,...