Diabetes In Elderly
| What is diabetes mellitus? | What is the impact of diabetes? | What causes diabetes mellitus? | What are the different types of diabetes mellitus? | What are the symptoms of diabetes mellitus? | How is diabetes mellitus diagnosed? | What is the oral glucose tolerance test? | What may the results of the oral glucose tolerance test indicate? | Why is blood sugar checked at home? | What is a hemoglobin A1c (A1c)? | What are the acute complications of diabetes mellitus? | What are the chronic complications of diabetes mellitus? | What can be done to slow diabetes complications? | How is diabetes treated? | Medications for type 2 diabetes mellitus? | Medications that increase the insulin output by the pancreas - sulfonylureas and meglitinides | Medications that decrease the amount of glucose produced by the liver | Medications that increase the sensitivity of cells to insulin | Medications that decrease the absorption of carbohydrates from the intestine | Treatment of diabetes with insulin | Different methods of delivering insulin | The future of pancreas transplantation | Diabetes Mellitus At A Glance | Diabetes Associated Bladder Dysfunction in Older Adult |
Diabetic cystopathy is a chronic complication of diabetes with a classic triad of symptoms: decreased bladder sensation, increased bladder capacity, and impaired detrusor contractility.
The effects of aging on renal function and the lower urinary tract can be exacerbated by superimposed chronic disease, particularly diabetes mellitus.
Diabetic nephropathy, a life-threatening condition, has received considerable attention. Diabetic cystopathy (DC) has received less, although it is a chronic complication that affects day-to-day life, predisposes individuals to urinary tract infections (UTIs), potentiates renal complications, and poses obstacles to optimum health.
It is insidious in onset, characterized by increased length of time between voiding. Prevalence is estimated to be between 32% to 45%.
Age-Related Changes to Urinary Tract Function
Cerebral control and central coordination of micturition is complex and not entirely understood.
Lesions in the cortex, such as those caused by stroke, transient ischemia, or a dementing illness, affect voluntary control as a result of damage to the centers for cerebral control and voiding coordination.
Recent changes to standardized terminology of lower urinary tract function relating to detrusor overactivity recognize the frequent relation to neurologic conditions, such as stroke, referring to this as neurogenic detrusor overactivity.
Urge incontinence in older women has been associated with increased risk of falls and nontraumatic fractures.
Age-related changes in the urinary tract are difficult to differentiate from those of disease pathophysiology.
Current thought suggests that cellular- and tissue-level aging includes smooth muscle degeneration and deposition of increased connective tissue, in addition to axonal degeneration and possible alterations to cholinergic (decreased muscarinic receptors) and adrenergic responses.
The age-related changes do not cause urinary incontinence, but they may predispose the elderly patient to:
Nocturnal urinary output also appears to change with age, with higher rates of urine excretion at night in older subjects.
Much of the research examining this phenomenon has involved frail hospital patients and nursing home residents, so whether variation in AVP level is a norm of aging or potentially a result of other disease processes is subject to debate.
Finally, functional limitations may contribute to incontinence in at-risk patients. For example, mobility changes or pain from musculoskeletal disease, such as arthritis or osteoporotic spinal compression fractures, can make toileting and continence difficult.
Agnosia and apraxia may develop in people with an Alzheimer dementia, leading to difficulties carrying out activities of daily living. These limitations, produced as effects of comorbid diseases, need to be considered in the assessment of the diabetic person with bladder dysfunction.
Effects of Diabetes on the Urinary Tract
The classic triad of bladder symptoms associated with DC includes decreased bladder sensation, increased bladder capacity, and impaired detrusor contractility with resultant increased postvoid residual (PVR) urine.
Increased PVR leaves the individual prone to UTIs, a common cause of acute confusion and functional decline in older adults. A possible link between deterioration of renal function and chronic asymptomatic bacteriuria in individuals with diabetes has been postulated.
Neuropathies in diabetics have been extensively studied in recent years, but none of these large trials included outcome measures relating to bladder dysfunction.
Increasingly, DC is described as a manifestation of autonomic neuropathy, although some believe it also represents peripheral somatic neuropathy.
Several classification systems for diabetic neuropathy have been suggested, but none has included specific lower urinary tract function.
Assessment of Bladder Dysfunction
Assessment of the older diabetic individual with symptoms of bladder dysfunction includes identification of age-related changes and risk factors arising from physiologic, psychosocial, and environmental influences.
History and Symptom Assessment
A description of the symptoms as experienced by the older adult or perceived by the caregiver is an important first step. Because DC is often insidious, the onset may be difficult to describe precisely.
The classic symptoms of overflow incontinence or reduced contractility bladder are weak stream, hesitancy in starting urination, dribbling (if high residual and resultant overflow incontinence are present), a sensation of incomplete emptying, leaking with increased abdominal pressure, and infrequent voiding.
Some elders present with only urgency and frequency, others with recurrent UTIs.
Physical examination includes complete neurologic evaluation with assessment of anal sphincter tone and saddle anesthesia.
Examination of the rectum assesses stool presence and consistency and, in men, prostatic size and shape. In women, a gynecologic examination assesses pelvic organ prolapse and pelvic floor muscle tone, estrogenization of the vaginal tissue, and the presence of Candida albicans, to which diabetic women are prone.
Because DC is a manifestation of autonomic neuropathy, screening for other signs of autonomic dysfunction may be included, particularly heart rate and orthostatic hypotension assessment measured by blood pressure while the patient is lying and standing.
Laboratory and Other Investigations
Microscopic urinalysis (and urine culture, if indicated), creatinine, blood urea nitrogen, and periodic urine microalbumin to assess renal function are part of initial assessment. Serum glucose and glycosylated hemoglobin, which reflects 2 to 3 months of glycemic control, also should be obtained.
Because one of the hallmarks of DC is an increase in residual urine, the PVR should be measured either by portable ultrasound or in-and-out catheterization.
Ideally, PVR should be measured within minutes of voiding. Norms for acceptable levels of PVR have not been established. A suggested normal range in the older adult is between 50 mL and 150 mL.
Urodynamic findings common to DC include impaired sensation, increased bladder capacity, reduced or absent detrusor contractility, inability to initiate voiding, and an increased PVR.
Psychosocial and Cognitive Assessment
Because older diabetics are at risk for stroke and impaired cognition, the assessment should include baseline mental status.
Little research has been published to guide practice in DC management. Evidence is modest at best for all interventions except glycemic control. Preventing further diabetes-associated neuropathy is an important goal in modifying or eliminating risk factors. Other management goals include symptom relief, infection prevention, renal function maintenance, continence, and adequate bladder emptying.
Hyperglycemia has been linked to neuropathy and other complications of diabetes. Strategies to achieve optimal glycemic control include diet (including increased fiber), exercise, and weight loss. Individuals with diabetes should be referred to a self-management teaching program for education on glycemic control. Age should not be a barrier to making an education referral. If cognitive impairment is an issue, the caregiver also must participate.
Individuals who are not able to attain this target by diet and exercise alone will require oral glucose lowering agents, insulin, or both.
Other preventive measures include hypertension and hyperlipidemia control and smoking cessation. Angiotension converting enzyme (ACE) inhibitors frequently are used in diabetes for both blood pressure control and treatment of atherosclerotic renal vascular disease.
The target blood pressure for individuals with diabetes is less than 130/85.
Scheduled Toileting and Double Voiding
Advising patients to void every two to four hours during the day and to use a double voiding technique may improve bladder emptying, improve continence, and minimize risk of infection. Because DC is gradual in onset, it may be useful to encourage the diabetic client to begin this habit even if the PVR is below 150 mL.
Double voiding involves attempting to empty the bladder by staying on the toilet and trying to void more than once with each trip to the toilet. Elders with cognitive impairment might need supportive cuing from caregivers to carry out the strategy.
These noninvasive strategies are worth trying, although their effectiveness has not been studied. Teaching these strategies should be followed with periodic measurement of PVR in patients with elevated residual urine to ensure that adequate bladder emptying is achieved.
Bladder expression, either by abdominal straining (Valsalva maneuver) or manual compression of the lower abdomen (Credé's maneuver), has been studied in the spinal cord population but not in the diabetic population.
Manual compression is contraindicated in the presence of increased intravesical (bladder) pressure, vasal reflux, or vesico-uretero-renal reflux. The effectiveness has not been systematically studied. Wein cautiously suggests this technique might be successful in those with an areflexic (hypotonic or atonic) bladder with some outlet denervation, presenting as stress incontinence.
Intermittent catheterization (IC) is one approach to achieve bladder emptying in DC when voiding strategies alone are ineffective.
Most of the research on IC has involved patients with spinal cord injury and children with myelomeningocele.
No evidence supports the choice of either sterile or clean technique in the diabetic population, and most individuals reuse catheters washed with soap and water and air-dried.
If urethral irritation occurs, a single-use hydrophilic catheter is available that provides an evenly lubricated mucoid surface and can be more comfortable than a standard plastic catheter inserted with a water-soluble lubricant.
However, many individuals may be uncomfortable with touching the urethra, and older women may be less likely to understand the anatomy of the female genitalia.
The most appropriate frequency of performing IC is not known. The important concept is to maintain a low vesicle pressure so that there is no reflux to the kidneys or risk to renal function.
Recommendations for catheterization vary from once, twice, or four times daily to developing an individual routine by use of a bladder diary, noting the combined volume of voided and catheterized urine with a total of 400 to 500 mL.
Strategies to Manage Nocturnal Polyuria
Nocturnal polyuria arises from possible age-related changes and from autonomic neuropathy in diabetes. Eliminating nocturnal polyuria may not be realistic, but the impact may be minimized by taking most of the fluid for the day in the morning or early afternoon, avoiding caffeinated beverages in the evening, and ensuring the bladder is empty before going to bed. Placing a commode by the bedside at night may reduce risk of falls and fractures.
No effective medications currently are available to assist with bladder emptying in DC.
Alpha blockers may be helpful in outlet obstruction from prostatic enlargement.
The above opinionated views and information serves to educated and informed consumer . The information provided herein should not be used during any medical emergency or for the diagnosis or treatment of any medical condition. .It should not replaced professional advise and consultation. A licensed physician should be consulted for diagnosis and treatment of any and all medical conditions
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