Case Study 3
A veteran aged eighty, living alone, diagnosed with diabetes mellitus type 2 (T2D) twelve years ago, displaying normal renal functioning, and prescribed insulin injections besides other oral anti-hyperglycemic drug (OAD), reported hypoglycemia attacks. Their potential consequences (unconsciousness or even, in extreme cases, death) frightened him. His attendant has been negligent in holiday and weekend periods, resulting in irregular insulin administration, which subsequently resulted in hypoglycemia episodes. As a result, the patient was prescribed insulin degludec; with time, this medication’s dosage was increased and he began displaying better fasting blood sugar and HbA1c levels, without hypoglycemia attacks. Case results indicate a combination of diet changes and degludec gave required diabetes control whilst ensuring no hypoglycemia episodes occurred.
Population
Over one-quarter of America’s 65+-aged population cluster is diabetes-diagnosed, with the general population’s aging being a key diabetes-endemic driving factor. Elderly diabetics depict considerable risks for chronic as well as acute cardiovascular and microvascular diabetes-related complications. In spite of being the age-group displaying greatest diabetes incidence, researchers typically neglect elderly individuals and individuals depicting multiple comorbidities when conducting therapeutic randomized control trials (RCTs) and diabetes and related ailments’ therapy target RCTs. Latest surveillance information reveals diabetes incidence in this age group to be between 22 and 33 percent, based upon applied diagnostic conditions. Other estimates indicate a 4.5-times increase in diagnosed diabetics of this age group from 2005 to 2050, as against the estimated trebling of the problem in the overall American population. Aged diabetics exhibit highest visual impairment, myocardial infarction, end-stage kidney disease, and severe lower-extremity (L-E) amputation among all age-groups (Jain & Paranjape, 2013).
Intervention
Aged diabetics’ disease management ought to consider their heterogeneity, unique desires and requirements (especially quality-of-life related goals), and pertinent goals right from the start. Elderly diabetics ought to be diagnosed via an in-depth geriatric evaluation. Physical and cognitive dysfunction and other geriatric ailments are commonly seen among aged diabetics, besides conventional vascular complications. Thus, in-depth geriatric evaluation ought to cover screening tests for geriatric, cardiovascular and microvascular complications. In case of inadequate or intolerable drug therapy, insulin ought to be prescribed for attaining proper glycemic control. Novel long-acting analogs of insulin are appropriate for aged patients, on account of their easy use and decreased hypoglycemia risks. Elderly patients and caregivers ought to be provided adequate education regarding hypoglycemia signs, hypoglycemia treatment, and blood sugar testing prior to insulin therapy commencement (Abdelhafiz & Sinclair, 2013).
Comparison
Stepwise glycemic therapy with continuous speedy interventions following therapy failure (HbA1C outcomes ?7.0%) is recommended. Insulin shots must be administered if such A1C results are exhibited 2 to 3 months following dual oral treatment. Once-a-day basal insulin (ODBI) is recommended for T2D patients. Besides prompt treatment commencement, swift dosage titration is vital to effective insulin therapy. T2Ds depict low risks of hypoglycemia at the start of insulin therapy, which makes intermediate–acting insulin most economical. In case of failure to achieve glycemic targets regardless of effective ODBI dosage titration or hypoglycemia, biphasic or prandial insulin ought to be integrated into treatment (Swinnen, Hoekstra, & DeVries, 2009).
Outcomes
Ultimately, ODBI treatment by itself cannot sustain glycemic control among innumerable T2D patients. When required A1C levels aren’t attained or sustained even after effective ODBI dosage titration, or when hypoglycemia limits aggressive titration, insulin administration is suggested. Alternatives at hand include another ODBI injection, biphasic insulin administration, or prandial insulin prior to a couple of meals. Whether to increase ODBI dose or introduce biphasic or prandial insulin ought to be decided on the basis of diurnal blood sugar profiles of individual patients. When contemplating profiles achieved via once-daily long-acting equivalent or intermediate-acting insulin, the impact apparently weakens in daytime, even among patients commencing treatment with insulin (that is, with the remaining internal insulin production) (Swinnen, Hoekstra, & DeVries, 2009).
Time
Researchers conducted a combined scrutiny of three open-label, randomized, phase III trials (duration; 22–26 weeks) (N = 1,296), comparing NPH (intermediate-acting insulin) against insulin detemir among elderly (aged above 65) and younger (aged below 65) patients displaying ineffectively controlled T2D. Based on study, subjects were administered ODBI or twice-daily basal insulin together with either OAD or bolus insulin. Mean fasting plasma sugar and A1C level modifications proved comparable for both treatment clusters and age groups. Overall relative hypoglycemia risks were found to be appreciably lower among detemir-administered patients as compared to NPH-administered ones among both age clusters. But relative nocturnal hypoglycemia risk proved to be ‘statistically significantly’ lesser for the younger detemir-administered cluster, though not among the elderly detemir-administered cluster (Moghissi, 2013).
References
Abdelhafiz, A. H., & Sinclair, A. J. (2013). Management of Type 2 Diabetes in Older People. Diabetes Therapy, 4(1), 13–26. http://doi.org/10.1007/s13300-013-0020-4
Jain, A., & Paranjape, S. (2013). Prevalence of type 2 diabetes mellitus in elderly in a primary care facility: An ideal facility. Indian Journal of Endocrinology and Metabolism, 17(Suppl1), S318–S322. http://doi.org/10.4103/2230-8210.119647
Moghissi, E. (2013). Management of Type 2 Diabetes Mellitus in Older Patients: Current and Emerging Treatment Options. Diabetes Therapy, 4(2), 239–256. http://doi.org/10.1007/s13300-013-0039-6
Swinnen, S. G., Hoekstra, J. B., & DeVries, J. H. (2009). Insulin Therapy for Type 2 Diabetes. Diabetes Care, 32(Suppl 2), S253–S259. http://doi.org/10.2337/dc09-S318
