Type 2 Diabetes Mellitus Assessment Answer

Doloris is an eight five year old delightful caucasian female who has been living in an old age facility for close to six years now. Doloris lost her husband ten years ago, post which she lived with her grandchildren for four years.  With her advancing age and illness, diabetes type 2 and Parkinson’s, it was difficult for her grandchildren to take adequate care of her.  Doloris was moved to the old age home when she was 79 years old, one year prior to her 80th birthday.  Though she has got used to her new home now, her heart aches to meet and be with her grandchildren, this constant sadness and pain makes her unwell often. This has also led her to develop signs of depression and loneliness.

Type 2 Diabetes Mellitus (T2DM) and Parkinson’s Disease

Doloris suffers from Type 2 Diabetes Mellitus (T2DM) and Parkinson’s disease (PD).  She was diagnosed with diabetes in her fifty’s. T2DM is a serious, common chronic disease that can occur due to various factors such as inheritance-environmental interactions in addition to increased risk factor such as obesity and sedentary lifestyle. It is characterized by chronic hyperglycemia and weakened or damaged carbohydrates, lipid or protein metabolism that is due to complete or partial lack of insulin secretion and/ or insulin action. Diabetes occur in two primary forms (i) T1DM (type 1 diabetes mellitus) which is insulin dependent and  (ii) T2DM (type 2 diabetes mellitus) that is non insulin dependent and accounts for 90-95% of all diabetes patients (Wu, et al, 2014).  Diabetes is known to be associated with  macrovascular (cardio and cerebro-vascular) and  microvascular (retinopathy, nephropathy, and neuropathy) complications, in addition studies show that other syndromes associated with old age such as cognitive impairment, sarcopenia, depression, falling, urinary incontinence, etc are associated with advanced aging (Bradly & Hsueh, 2016; Yakary, et al, 2017). It is observed that glucose intolerance increases progressively by aging and postprandial hyperglycemia being the most common feature of diabetes in the elderly (Figure 1). 

Model and Strategies of Care for a Patient Suffering from T2M and PD

Due to lack of clear concise clinical guidelines for diabetes management in patients suffering from T2DM and PD, the specialized care and the quality of care imparted to the patients are based on guidelines laid down for clinical practice for the  individual diseases. E.g. there are different guideline for treating diabetes (e.g. guidelines American Diabetes Association) and PD (e.g. European Parkinson’s diseases Standards of Care Consensus Statement). It is estimated that prevalence of PD will increase many folds by 2030, due to aging among the population becoming a major public concern. Normally three process of care are followed- (i) HbA1c testing- conducted two times a year with a minimum gap of three months at least, (ii) lipid testing – conducted at least once a year and (iii) nephropathy screening performed once a year.  HbA1c> 9%  indicates poor glycemic control while HbA1c < 8%  is considered acceptable glycemic control among the elderly.  Lipid control results are based on LDL-C (Low Density Lipid Cholesterol), HDL-C (High Density Lipid Cholesterol, triglycerides  and total cholesterol (Bhattacharjee & Sambamoorthi, 2015).  

Patients with multi morbidities special care is needed as broad variety of  potential interaction between the different diseases and their treatments can make the course of the disease worse, cause unnecessary symptoms (that can be avoided),  complicate the diagnostic-work up which in turn can affect the course of the treatment. To avoid this some mechanisms are checked before the patient is treated viz., drug-drug, drug-disease, and disease-disease interaction.  Conducting this study would not only keep adverse drug reaction at bay but also take care of reduced adherence and risk of polypharmacy (Muth, et al, 2014).

Specialist Parkinson’s nurses are normally assigned to take care of patients suffering with PD.  These nurses help the patients with the complex conditions, numerous medication, offer guidance and educate them on ways of leading their life with PD.  They also offer emotional support to patients and their families’ right from the beginning of the illness through the palliative treatment stages until the end- of -life.  These nurses are specialized as they can manage the constant fluctuations and the drug adjustments necessary to manage the complex neurological symptoms (Cotton, 2012).

Challenges in Managing T2DM and PD in Elderly patients- Ethical and Legal Issues

Many challenges are faced by a healthcare professional while managing elderly patients with multiple morbidities. One of the primary challenges by healthcare professionals such as nurses is the presence of several comorbidities that need complex care due to multiple medication regimes, patients being vulnerable to isolation and constant depression, in addition to risks of adverse events such as falling and mismanagement/ negligence of medicine (Graue, et al, 2013). In the case of Doloris as we have seen earlier, she suffers from multiple morbidities such as T2DM, PD, and depression to name a few. The main hurdles that come in way of sound clinical management of elderly patient are

(i) availability and accessibility of information and support- e.g. imparting diabetes related knowledge to patients, relatives and colleagues, which would require the attending nurse to be knowledgeable and proficient in diabetes care, improved team communication, and agreement on ways to implement evidence-based guidelines

(ii) lack of  professional confidence and autonomy- nurses feel that they required adequate training and support to give them enhanced proficiency and confidence to take autonomous decisions, and

(iii) professional cohesion- this is often found lacking and the inadequate teamwork and inconsistency would lead to substandard care.

(iv) prioritizing and balancing care of the patient alongside documentation required to aid with the regulations and standard of care, though difficult to achieve must be adhered to for providing the best possible care (Graue, et al, 2013).  It is imperative for the healthcare professionals to be cautious in providing individualized diabetes treatment especially for elderly with multiple chronic illnesses making the care more complex. This is particularly important as two or more older adults may have similar morbidities thus tempting the providers in assigning similar care goals, however, each case must be individually considered and weighed before formulating the best approach (Hackel, 2013).E .g. in the case of Doloris- though she has T2DM and PD, but her matters become unique as she suffers from depression and loneliness as well which makes matters difficult in her case.

Healthcare professionals face many ethical challenges for treating older aged patients with PD due its diverse presentation of symptoms that spans across many years besides the late onset of complications of dementia. Four key themes to ensure ethical and legal practices are followed in taking care of such patients are -

(i) information giving,

(ii) identity,

(iii) coping and

(iv) future medicine (Shaw & Vivekananda-Schmidt, 2017).  

Maintain Quality of Life in Elderly Suffering from T2DM and PD

T2DM is one of the most severe health threats there is around the world.  Diabetes is synonymous with unhealthy life-style, behavioral and socio-economic change.  A recent line of thought to counter this is by using the “empowerment and involvement” of patients for their daily self-management of diabetes.  In elderly patients, this would also keep them active and aware and help take their mind off sad , depressing thoughts such as missing her grandchildren in Doloris’s case.  Patient empowerment means that - the healthcare professionals’ aid the patients make informed decisions in agreement with certain circumstances.  It is a patient-centric collaborative approach that helps patients takes charge of their own life. This approach has proven to improve the health and welfare of patients and improve their quality of life. The key empowerment skills comprise of (i)  solving problems, (ii) boosting self-confidence, and (iii) creating strategies to gain mutual trust. This begins by providing the patient with the necessary  information and ends when the patient is capable of making smart decision for herself (Tol, et al, 2015).

The Right to Know

A terminally-ill elderly patient with multiple morbidities needs to know the various end-of life options      available including but not limiting to hospice, palliative care, refusing or withdrawing life-prolonging treatment, and euthanasia (Gross, 2008).  Though euthanasia is currently illegal in Australia, the state of Victoria will be allowing doctor-assisted suicide from mid-2019 (McGuirk, 2017).

Conclusion

Doloris, the delightful 85-year old patient suffering from T2DM and PD in addition to depression and loneliness is the subject of this case study.  Though she has multiple morbidities, Doloris is a good patient who is currently taking her medication and treatment plan seriously.  She and her family members have been explained in detail the various ethical and legal  implication of her course of treatment and care. Though, Doloris follows the “patient-empowerment” protocol, there are times when she feels her life is empty, not worth living especially when her clinical symptoms due to T2DM and PD aggravate.  She has been given information of various end-of –life options and though she has said ‘no’ she is aware and conscious that she has a choice before her should her suffering be unbearable.

Reference

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