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 every 6 months. Other neurological conditions must be ruled out before a diagnosis of diabetic neuropathy is made. The patient should be informed that symptoms of diabetic neuropathy may improve slowly with improved glycaemic control.

All elderly people with diabetes should be reviewed at least 6-monthly for refraction, and at least yearly for ophthalmoscopic examination with pupil dilatation. Detection of any retinopathy, cataract or other ocular abnormality warrants referral to an ophthalmologist. Early retinopathy can be reversed by improved metabolic control or halted by laser therapy.

Table 3.5 Initial screening for chronic diabetic complications

Atherosclerotic disease Cardiovascular examination Electrocardiogram

Serum total cholesterol, HDL cholesterol and triglycerides Neuropathy

Neurologic examination, with particular attention to peripheral sensation and autonomic nervous system (valsalva manoeuvre, postural hypotension, sinus arrhythmia)

Eye disease Visual acuity

Fundoscopy with pupils dilated

Nephropathy

Dipstick urinalysis for protein

Microalbuminuria if negative dipstick proteinuria

Quantification of proteinuria and creatinine clearance if dipstick for proteinuria is positive Serum creatinine and urea Blood pressure

Foot problems

Vascular, neurologic, musculoskeletal and cutaneous and soft tissue examination of the feet Examination and improvement of footwear

Renal function should be monitored at least annually by measurement of microalbuminuria and plasma creatinine. Urinalysis should be checked regularly to detect occult urinary tract infection. Strict control of hypertension is important for preventing or reversing early diabetic nephropathy.

The feet should be examined at every visit to the physician. Ulcers and infection must be treated promptly. A podiatrist should be involved in the education and management of footcare (see Chapter 6).

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