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Running head: DIABETES MELLITUS IN OLDER ADULTS

Research Paper: Diabetes Mellitus in Older Adults

Diabetes Mellitus in Older Adults


Introduction
Diabetes mellitus encompasses a group of diseases characterized by high levels of blood
glucose resulting from the bodys failure to produce insulin (insulin-dependent Type 1) or
inability to process insulin (non-insulin-dependent Type 2). It is a metabolic disorder that affects
carbohydrate, fat and protein metabolism in the body. Type 1 is typically seen in children and
young adults, although the disease onset can begin at any age.
The main discussion will be of Type 2 diabetes as it pertains to older adults. Other
classifications include prediabetes (elevated blood glucose levels but not enough to be
considered Type 2) and gestational diabetes (develops during pregnancy). This paper examines
the etiology, epidemiology, pathophysiology, clinical manifestations, evaluation, management
and nursing concerns of diabetes mellitus in the elderly population.
Etiology

DIABETES MELLITUS IN OLDER ADULTS

The risk factors for Type 1 diabetes include genetic, autoimmune and environmental
factors. Previously called juvenile-onset diabetes, a genetic predisposition is the main cause for
this type of diabetes although environmental factors such as a virus may trigger the disease as
well. Mauk (2014) states that older age, a family history of diabetes, obesity, race (African
Americans, Hispanics Native Americans, Asian Americans, Pacific Islanders), hypertension,
decreased HDL levels, physical inactivity, polycystic ovary syndrome, and a history of
gestational or prediabetes are all risk factors for Type 2 diabetes.
People beyond age 45 are at an increased risk of getting diabetes. This is due to lifestyle
changes in older age including less regular exercise and the bodys natural decrease in muscle
mass. In this way, old age increases many other risk factors for developing diabetes.
Having a family history of diabetes means it is highly likely that the person will develop
diabetes because of the genetic link. For the older adult, this is especially important because it is
a non-modifiable risk factor and makes the person directly vulnerable to the disease regardless of
any other factors.
Mayo Clinic (2014) explains that obesity is a primary risk factor directly related to the
development of diabetes due to the added stress on the bodys ability to use insulin to properly
control blood sugar levels, which can make the body become resistant to insulin due to the
increase in the amount of fatty tissue in the body. This is a common issue with older adults who
tend to not exercise regularly leading to difficulties with managing weight, and over time, the
prolonged effects on the body can cause diabetes.
Epidemiology
Diabetes mellitus is the seventh leading cause of death among older adults (Mauk, 2014).
According to the Centers for Disease Control and Prevention (2014), 29.1 million people (9.3%
of the population) have diabetes. That is about 1 out of every 11 people just in the U.S. Of those,
21 million people are diagnosed and 8.1 million remain undiagnosed. The risk of death for adults

DIABETES MELLITUS IN OLDER ADULTS

with diabetes is 50% higher than those without diabetes. 15-30% of people with prediabetes will
develop Type 2 diabetes in five years without proper weight management and physical activity.
Pathophysiology
Type 1 diabetes develops when the bodys immune system destroys pancreatic beta cells,
the cells in the body responsible for making the hormone insulin to regulate blood glucose levels,
resulting in chronic hyperglycemia. However with Type 2 diabetes, a genetic predisposition
along with obesity causes insulin resistance in the body. Glucose is not properly utilized and high
levels remain in the blood causing hyperglycemia. The body then starts to produce too much
insulin and as the need for insulin increases, the pancreas gradually loses its ability to produce
insulin. Eventually the beta cells stop working properly, leading to inadequate insulin secretion
which then develops into chronic hyperglycemia in the body and diabetes (Mayo Clinic, 2014).
Clinical Manifestations
The clinical manifestations of diabetes mellitus include excessive thirst (polydipsia),
frequent urination (polyuria), blurring of vision, increased fatigue, slow healing cuts or sores, dry
and itchy skin and numbness or tingling of feet (National Institute on Aging, 2012). Unexplained
weight loss also occurs due to the increased breakdown of fat from insulin resistance. Older
adults may also have urinary incontinence related to polyuria, which can cause dehydration.
Evaluation
There are several diagnostic tests for diabetes as noted in Hale (2014). These are often
taken on two separate occasions. A random/casual glucose test is taken at any time of the day and
the criteria for diabetes is a blood glucose of 200 mg/dl or higher. A fasting glucose test is taken
after going without food for at least eight hours, and is positive for diabetes with blood glucose
126 mg/dl or higher. An oral glucose tolerance test is taken after fasting overnight and then again
two hours after ingesting glucose, with blood glucose 200 mg/dl or higher.
The hemoglobin A1C test is used to monitor the average amount of glucose in the blood
over the last few months. Glucose permanently attaches to hemoglobin in the blood, which is

DIABETES MELLITUS IN OLDER ADULTS

why this test is frequently used to determine the extent of uncontrolled blood glucose in the body
over a period of time. An A1C range of 6-7% indicates optimal glycemic control.
Management
The management of diabetes mellitus in the older adult is a combination of diet, exercise
and medications (Mauk, 2014). Meal planning and diet control helps with regulating weight and
the goal is to keep the body weight at a normal range. A higher intake of high fiber and low-fat
foods such as fruits, vegetables and whole grains and a reduction in foods high in fat and sugar
are optimal to long-term diabetes management (Mayo Clinic, 2014). Exercise burns calories,
which also helps in maintaining weight. It also stimulates proper insulin function, allowing the
bodys production of insulin to work more efficiently and improves glucose levels in older adults
(NIA, 2012). Medications may include oral hypoglycemic agents and/or insulin injections. A side
effect of insulin is hypoglycemia, so it is important for the older adult to understand the signs and
symptoms of hyperglycemia and hypoglycemia and know how to monitor blood glucose.
Some people are able to manage diabetes just through diet and exercise, while others
often need pharmacologic interventions. Mayo Clinic (2014) lists a few examples of
medications: metformin (Glucophage, Glumetza), sulfonylureas, meglitinides and insulin
therapy. Metformin is typically the first medication prescribed for Type 2 diabetes, which
improves the bodys sensitivity to insulin and also lowers glucose production in the liver.
Glyburide (DiaBeta, Glynase), glipizide (Glucotrol) and glimepiride (Amaryl) are medications in
the classification of sulfonylureas, which help the body secrete more insulin. Meglitinides such
as repaglinide (Prandin) and nateglinide (Starlix) are similar to sulfonylureas in terms of action
on the body, except these are faster-acting and have a lower risk of causing hypoglycemia.
Nursing Concerns
The main nursing concerns for diabetes fall under education, management and
prevention. The nurse works with the older adult to plan treatment goals that will prevent long

DIABETES MELLITUS IN OLDER ADULTS

term complications such as heart and kidney problems in the older adult. Older adults should also
be educated to practice good and safe self-care techniques.
It is essential for the nurse to emphasize eating healthy foods and following a diet
program, and may include a referral to a registered dietician if necessary. Other important
teaching issues include the importance of getting enough exercise and how to monitor blood
sugar in response to food, exercise, illness and medications. This includes teaching of how to
use a glucometer to check blood sugar, as well as how to assess for signs of hyperglycemia
(frequent urination, dry mouth, nausea, fatigue) and hypoglycemia (sweating, shakiness,
dizziness, hunger).
Within this area, the nurse should be able to evaluate the proficiency of the older adult in
administering medications for themselves. Nurses should consider if there are vision problems or
the client has a history of arthritis. If the older adult has anxiety about administering medications
themselves, family members and caregivers can be taught how to give insulin. Family members
are a vital part of the disease prevention process and are also required to understand care for
diabetes. For example, they need to learn about diabetes, recognize signs and symptoms and
attend diabetes education classes if needed.
Managing proper foot care is also important in the diabetic patient due to the increased
risk of infection and slow healing that occurs with the disease process, reducing the risk for
amputation (Mauk, 2014). The nurse should demonstrate proper foot care behaviors to never go
barefoot outside, always wear well-fitting shoes, prevent exposure to extreme temperatures,
inspect the feet daily and see a podiatrist for foot inspection annually.
Depending on when diabetes is diagnosed in the older adult, macrovascular and
microvascular diseases caused by diabetes may or may not have progressed. Mauk (2014) notes
that it is important to continuously monitor and assess for the development of these
complications. Coronary heart disease, stroke and peripheral vascular disease are macrovascular

DIABETES MELLITUS IN OLDER ADULTS

diseases that potentially could lead to amputation. Chronic kidney disease leading to end-stage
renal disease and diabetic neuropathy (leading factor of blindness) are some of the common
microvascular complications. Peripheral neuropathy is another concern due to the lack of
sensation, and this can also contribute to a higher risk for falls along with urinary continence due
to the increased dizziness caused by dehydration. The nurse is most concerned with the
management of pain and the maintenance of a healthy lifestyle. In this situation, physical therapy
may also be helpful to the treatment process.
Conclusion
Diabetes is one of the most dangerous and prevalent diseases affecting both the young
and old. It is important for both the healthcare professional and the client to be patient because
this is a serious lifelong disease. Planning treatment goals and establishing a diet/exercise and
medication regimen is essential to maintaining a healthy lifestyle and preventing as many
complications of the disease as possible. This allows the older adult to have responsibility and
control over his or her diabetes management.

References
Mauk, K. L. (2014). Gerontological nursing: Competencies for care (3rd ed.). Burlington, MA:
Jones and Bartlett Learning.
Centers for Disease Control and Prevention. (2014) A snapshot: Diabetes in the United States
[Data file]. Retrieved from http://www.cdc.gov/diabetes/pubs/statsreport14/diabetesinfographic.pdf

DIABETES MELLITUS IN OLDER ADULTS


National Institute on Aging. (2012) Diabetes in older people: A disease you can manage [Data
file]. Retrieved from
http://www.nia.nih.gov/sites/default/files/diabetes_in_older_people_0.pdf
Mayo Clinic Staff. (2014). Type 2 diabetes: Risk factors. Retrieved from
http://www.mayoclinic.org/diseases-conditions/type-2-diabetes/basics/risk-factors/con20031902