1.DIABETES MELLITUS ISSUES IN THELONG TERM CARE SETTING AND ALLIED VENUES

2. DIABETES MELLITUS

Focus:diabetes in the Medicare population

3. DIABETES MELLITUS

Definition: a metabolic disorder in which

there is deficiency of insulin production or

resistance of organs to the effect of insulin

4. DIABETES MELLITUS

Diabetes is a disorder of metabolism--the way our bodies use digested food for growth and energy.

Most of the food we eat is broken down into glucose, the form of sugar in the blood.

Glucose is the main source of fuel for the body.

5. DIABETES MELLITUS

After digestion, glucose passes into the bloodstream, where it is used by cells for growth and energy.

For glucose to get into cells, insulin must be present.

Insulin is a hormone produced by the pancreas, a large gland behind the stomach.

6. DIABETES MELLITUS

NORMAL: When non-diabetic people eat, the pancreas automatically produces the right amount of insulin to move glucose from blood into our cells.

7. DIABETES MELLITUS

DIABETES: In people with diabetes, when they eat,the pancreas either produces little or no insulin, or the cells do not respond appropriately to the insulin that is produced (or both)=> glucose builds up in the blood, overflows into the urine, and passes out of the body in urine => body loses its main source of fuel even though blood contains large amounts of glucose.

8. DIABETES MELLITUS (DM)

TYPES OF DIABETES

• • • Type I

• • • Type II

• • • MODY (Maturity Onset Diabetes of Youth

• • • Gestational

9. DM TYPE I

Auto-immune disease

Constitutes 5-10% of DM diagnosed in the USA

Mostly appears in children and young adults

Develops as a result of auto-immune destruction of beta-cells in the pancreas

Presents with polyuria, thirst, weight loss, marked fatigue

Can be complicated by coma with ketoacidosis

10. DM TYPE II

Most common form of diabetes

Involves about 90-95% of people with DM

Associated with:

• older age

• obesity

• family history of DM

• prior history of gestational diabetes

• physical inactivity

• ethnicity

11. DM TYPE II

Patient with type II DM usually makes enough insulin but the body cannot use it effectively =>insulin resistance

Graduallyinsulin productiondecreases over the following years

Symptoms are similar to type I but develop more gradually

12. DM TYPE II

Symptoms of type II DM include:

• Fatigue

• Nausea

• Frequent urination/polyuria

• Thirst

• Unusual weight loss

• Blurred vision

• Frequent infections

• Slow healing of wounds or sores

• Sometimes no specific symptoms

13. GESTATIONAL DIABETES

Develops only during pregnancy

More common in:

• African Americans

• American Indians

• Hispanic Americans

• women with a family history of diabetes

Women with a history of gestational diabetes have a 20-50% chance of getting type II DM within 5-10 years

14. Diabetes Mellitus: Diagnosis

Fasting plasma glucose =preferred test : Positive test is glycemia of 126mg/dL or higher after fasting at least 8 hours

Random plasma glucose of 200mg/dL or higher along with symptoms of diabetes

Oral glucose tolerance test (OGTT) plasma glucose of 200mg/dL or higher done 2 hours after ingestion of 75 grams of glucose in water

MKSAP13 Endocrinology and Metabolism. American College of Physicians 2004.

15. Diabetes Mellitus

Hemoglobin A1c measurement isnotrecommended currently for diagnosis of diabetes.

HbA1c is used as a marker to monitor glycemia control in patients over time

MKSAP13 Endocrinology and Metabolism. American College of Physicians 2004.

16. Pre-Diabetes

Pre-diabetes refers to a state between normal and diabetes= fasting plasma glucose 100-125mg/dL (higher than normal but not high enough for diagnosis of diabetes) Affects about 41 million people in USA (previously referred to as either impaired fasting glucose or impaired glucose tolerance)

http://diabetes.niddk.nih.gov/dm/pubs/overview/index.htm#types

MKSAP13 Endocrinology and Metabolism. American College of Physicians 2004.

17. Type II Diabetes

Diagnostic testing - when to do it:

People45 years old=> if normal then every 3 years

MKSAP13 Endocrinology and Metabolism. American College of Physicians 2004.

18. Type II Diabetes: diagnostic testing

Youngerthan 45 yo or more often than every 3 years if:

overweight

first degree relative with diabetes

member of high risk ethnic group (Afro-American, Hispanic American, Native American, Asian American, Pacific Islander)

delivered a baby9 lbs.

gestational diabetes

hypertensive (BP140/90mmHg)

High Density Lipoprotein cholesterol 35mg/dl or less

TriGlyceride level 250mg/dl or more

pre-diabetes

MKSAP13 Endocrinology and Metabolism. American College of Physicians 2004.

19. DM type II: Management

Basics:

healthy eating

physical activity

blood glucose testing

Pharmaceuticals:

oral medication(s)

insulin(s)

both oral medicines and insulin

20. DM: insulin variations

Daily insulin requirements are influenced by:

diet

exercise

stress

21. Diabetes Management: Stress

Stress influences response to insulin

Stress =>increased cortisol

increased catecholamines

increased growth hormone

=> these hormones all lead to increased insulin resistance (thus, hyperglycemia)

22. Control of Diabetes

Control of Diabetes includes:

glycemia control (FBS < 126mg/dL; HbA1c pharmacotherapy (medications)

24. Insulins

Type hours to onset time to peak time effective

Fast acting:

Lispro 7%despitelife style modification and 2 oral medications

May be postponed in borderline cases where HbA1c is < 8.5% pending addition of a 3rd oral agent; otherwise =>

Addition of bedtime dose of basal insulin therapy (glargine) to sulfonylureas +/- metformin (not thiazolidinediones because of risk of CHF from fluid retention)

29. The Metabolic Syndrome

Hypertension

Visceral (central) obesity

Hypertriglyceridemia

Low HDL cholesterol

Insulin resistance or glucose intolerance

Prothrombotic state (high fibrinogen or plasminogen activator inhibitor [-1] in blood)

Proinflammatory state (high C-reactive protein in blood)

http://www.americanheart.org/presenter.jhtml?identifier=4756

30. Acute Complications of type II DM

Hyperglycemic hyperosmolar state:

common in elderly

triggered by underlying disorder(s)

risk increased in elderly due to decreased thirst reflex

often complicated by delirium

31. Acute Complications of type II DM

Hyperglycemic hyperosmolar state:

serum osmolarity > 320 mosm/L

plasma glucose > 600mg/dL

dehydration

no ketoacidosis

underlying disorder(s)

32. Hyperosmolar State

Therapy:

rehydration with hypotonic solution

insulin infusion (initially)

watch for signs of fluid overload/CHF

monitor potassium

treat underlying cause (eg UTI, cellulitis)

33. Hypoglycemia

Hypoglycemia = plasma glycemia < 50mg/dL with or without symptoms

More common in type I DM and patients with significant renal or liver disease

Another reason for glucose monitoring

Treated with po sugar (e.g. fruit juice or glucose tablets)

or IV dextrose 50% in water orIV glucagon or both

34. Complications of DM

Chronic complications of diabetes mellitus include:

Macrovascular

Microvascular

Neuropathic

35. Complications of DM

Macrovascular

atherosclerosis/cardiovascular disease

peripheral vascular disease

36. Complications of DM

Microvascular diabetic retinopathy : due to ischemia of retna; provokes neovascularization with vessels more fragile => leaking => scarring & fibrosis

diabetic nephropathy :common cause of ESRD;

prevention via control of blood pressure and glycemia; earliest signs urine albumin 30mg/day or 20 g/min; appears to benefit from ACE-Is and ARBs too

37. Complications of DM

Diabetic Neuropathy

peripheral sensory neuropathy

cardiovascular autonomic neuropathy

gastrointestinal autonomic neuropathy

erectile dysfunction

mononeuropathy

diabetic foot

38. Complications of DM

Peripheral sensory neuropathy

variable presentation

dysesthesia

tingling

pain

loss of pain sensation (risk of injury)

39. Complications of DM

Cardiovascular Autonomic Neuropathy

orthostatic hypotension

lack of normal variation in heart rate with breathing, tachycardia

40. Complications of DM

Gastrointestinal Autonomic Neuropathy

gastroparesis: nausea, bloating, vomiting (tx metoclopramide)

diarrhea: often nocturnal

41. Complications of DM

Erectile dysfunction:

autonomic neuropathy

absent nocturnal and morning erections

more common than diagnosed

42. Complications of DM

Mononeuropathy

acute local pain

distribution of a nerve

may recede if treated early with improved glucose control (glucotoxicity)

43. Complications of DM

Diabetic Foot

sensory deficit (skin, bone, ligament)

fungal infection

wounds

pulses (PVD)

slow healing

ulcers

44. Type II DM: Goals

Prevention of pre-diabetes

Prevention of change from pre-diabetes to diabetes

Diagnosis through screening

Early management/therapy

Prevention of complications

45. Type II DM: Goals

Screening via fasting glycemia and history

Life-style history and modification

Physical activity

Diet

Treatment of glycemia, lipids, hypercoagulable state, blood pressure

Management of complications

46.