DM in older osteoarthritis
DIABETES MELLITUS IN THE ELDERLY
When diabetes mellitus makes its appearance, most pancreatic beta cells are already destroyed. Nature the process is almost certainly destructive immune based, although the details of it remain obscure. The pathogenesis starts with a genetic susceptibility to disease, and some environmental events begin the destructive process in vulnerable individuals.
The condition of the patient is while it is occurring, albeit undetectable, the immune attack is called prediabetes. The prediabetic state may be brief or prolonged, it is sometimes interrupted, and other progressive and intermittent. What is clear is that stocks are steadily diminishing insulin until they are insufficient to maintain blood glucose at normal levels. It is at this time it is diagnosed diabetes.
An increase in the ratio of fat to lean body mass decreases insulin sensitivity: Studies have shown that the number of insulin receptors does not change with age, but the deterioration of glucose uptake mediated by this hormone may be due to postreceptor defects.
Elderly people also have high levels of insulin. This change could be explained by resistance to it, reduced degradation of this hormone or both. You may have a site deterioration of beta cell function, but autopsy studies indicate that aging does not change its morphology.
declines with age glucose tolerance. There is general agreement that the glucose intolerance of aging is a normal process of the same or an abnormality to be corrected.
diabetes mellitus are commonly seen in older people. It is possible that at the time of diagnosis there are no classic symptoms such as polydipsia, polyuria and polyphagia.
The most common type in older people is diabetes mellitus non-insulin dependent, also called type II.
In this type of diabetes the pancreas continues to produce insulin, even at higher values \u200b\u200bof high-normal. However, the body develops a resistance its effects and the result is a relative insulin deficiency. Type two diabetes occurs in children and adolescents, but usually starts after thirty years and is more common after that age, obesity is a risk factor for type two diabetes and obesity that include between 80% and 90% of people suffering from this disease.
type one diabetes or non insulin dependent, where the production of little or no insulin. Despite being a highly prevalent disease with only 10% of diabetics have type one disease. Most patients with type one developed the disease before age 30. The
Scientists believe that an environmental factor (possibly a viral infection or a nutritional factor in childhood or adolescence) leads to destruction by the immune system cells that produce insulin in the pancreas. It is more likely that a genetic predisposition is necessary for this to happen. Anyway, type one diabetes for over 90% of the cells that produce insulin in the pancreas (beta cells) are destroyed irreversibly. Insulin deficiency is severe and therefore to survive a person with this condition must inject insulin deficiency. PREVALENCE
The prevalence of diabetes mellitus is 7 to 10% in those over 65 years of age and increases with aging. The index can be as high as 15% in nursing home populations.
Possible factors contributing to increased prevalence are:
• Weight gain • Low physical activity
• Impaired glucose uptake mediated by insulin postreceptor defects
•
CRITERIA FOR THE DIAGNOSIS
The National Group criteria for data on diabetes diagnosis was based on the values \u200b\u200bof fasting blood glucose, relatively unchanging with age, and studies have shown to increase 1 to 2 mg / dl / decade after 50 years. Useful criteria for diagnosis are:
1. Fasting glucose> 140 mg / dl, accompanied by symptoms
2. Random blood glucose> 200 mg / dl, accompanied by symptoms
very obese people with a family history of diabetes or gestational diabetes are considered high risk. These groups must be carefully weighed and measured their blood glucose levels at random as part of periodic health examinations.
COMPLICATIONS:
Ketoacidosis: characterized by urinary loss of water, potassium, ammonium and sodium in hypovolemia, electrolyte imbalance, elevated very important for glucose levels in blood and degradation of free fatty acids. The patient has a hot, dry skin, restlessness, agitation, diaphoresis, and a characteristic breath odor of nail polish remover. Without a good immediate treatment and can cause death and must be to provide large amounts of intravenous fluids and electrolytes like sodium, potassium, chloride and phosphate to replace those that are lost excessively.
Insulin given intravenously so that it acts quickly and the dose should be adaptable. Blood levels of glucose, ketones, and electrolytes are measured every few hours which can tailor treatment to the needs each time.
must also be taken arterial blood samples to determine its acidity. Diabetic foot
:
At this time, the most important causes of morbidity and mortality of diabetes are the chronic complications of diabetes. Among them are the diabetic foot that occurs from 15% to 20% of diabetics. This is a public health problem for high frequency and for its enormous health and social costs generated by the high number of hospital admissions, prolonged hospitalization, the demand for medical care and work incapacity of patients, among others.
To address this problem, it is interesting to highlight some epidemiological data:
• Approximately 20% of diabetics develop foot ulcers at some point in their lives.
• According to several studies, between 50% and 95% of cases of lower limb amputations are caused by diabetes.
• In men and women aged 80 years almost 2 / 3 of arteriosclerotic gangrene cases are the result of diabetes.
• In 40% of amputees will produce a second amputation within 5 years with a 50% mortality within the first 3 years.
Pressure Ulcers
Are skin lesions that occur as a result of a lack of blood and irritation of the skin over a bony prominence in areas where it has been pressed.
Causes:
• Blood supply low in the skin for 2 to 3 hours under pressure.
• Immobilization, with involvement of the muscles or limitation of motion due to pain.
• Injury to a nerve injury or stroke or diabetes reduced the ability to feel pain.
• Malnutrition, deprived of essential nutrients that prevent healing.
• inappropriate clothing, bedding, or friction from shoes against the skin can contribute to skin damage.
• Prolonged exposure to humidity (often by sweating, urine or feces) can damage the surface of the skin.
Pressure ulcers are classified into 4 stages:
• Stage I: Erythema of the skin that does not blanch (difficult to estimate in patients with deeply pigmented skin).
• Stage II: Alterations in the dermis, but not in the subcutaneous tissue.
• Stage III: The ulcers spread subcutaneous tissue deep to the fascia.
• Stage IV: The ulcer comprised of the depth of the fascia to the bone.
Hyperosmolar Coma:
hyperosmolar diabetic coma, nonketotic, is usually a complication of non-insulin dependent diabetes. Is a clinical dehydration caused by deep-induced diuresis, hyperglycemic sustained in circumstances where the patient can not drink enough water to compensate for urinary loss of fluid. Typically, a diabetic elderly, who often live alone or are in a nursing home, suffers a stroke, infection or worsening the hyperglycemia and prevents you from drinking enough water. Probably the full clinical picture does not develop until the blood volume reduction is strong enough to cause a decrease diuresis. Hyperosmolar coma can also be triggered by diabetes peritoneal or hemodialysis, for tube feeding with protein-rich preparations for intravenous drips rich in carbohydrates, and by the use of osmotic agents such as mannitol and urea. Have also been reported cases caused by phenytoin, corticosteroids, immunosuppressive agents and diuretics.
Clinically these patients present with severe hyperglycemia, hyperosmolarity, dehydration with reduced blood volume and central nervous system manifestations ranging from lethargy to coma. Are not infrequent seizures, Parkinsonian-like sometimes, and can be seen hemiplegia transient. Often there are infections, especially pneumonia and gram-negative sepsis, indicating a grave prognosis. There may be bleeding, probably caused by disseminated intravascular coagulation and acute pancreatitis is sometimes observed.
neuropathic Charcot arthropathy.
is a result of nerve injury, preventing joint pain perception by the person concerned. Therefore insignificant injuries and fractures, repetitive unnoticed, until the accumulated damage destroys the joint permanently.
Factors influencing the formation of atherosclerosis in diabetics:
Smoking:
promotes atherosclerosis by several mechanisms such as the toxic action of nicotine to the release of catecholamines and a spastic vessel direct effect, by decreasing the oxygen concentration of carbon monoxide increased the amount of carboxyhemoglobin, and by increased platelet aggregation and adhesion with decreased fibrinolysis.
Obesity:
The risk increases with body mass indexes above 30, another element to consider would be the fat distribution as hyperlipoproteinemia.
Hyperlipidemia:
in diabetics is given by the excess or deficiency of insulin where there is increased intestinal absorption of fats and cholesterol and glycosylation of apoproteins.
Hypertension:
development of atherosclerosis is less influential in the lower limbs. He is considered a factor especially once angiopathy associated with smoking and diabetic microangiopathy. Sedentary
:
Exercise leads to increased muscle tone and enhances collateral circulation is therefore of fundamental importance in diabetes that is so is considered a mainstay of treatment of diabetic patients.
Genetic factors: increased susceptibility
Presents individual related to the presence of blood group A. Vascular complications
:
Diabetic patients have a risk 2 to 3 times more myocardial infarction and stroke than people without diabetes. In type II diabetes, 60% of mortality due to vascular disease. Hyperglycemia, hyperinsulinemia, and hyperlipidemia are associated with vascular disease and diabetes usually seen in elderly. In addition, diabetics are prone to hypertension and obesity, which are also risks of coronary heart disease.
One complication is peripheral arterial disease that occurs through several stages:
• Stage 0: The existence of asymptomatic vascular disease, demonstrable only by exploration.
• Stage 1: Intermittent claudication.
• Stage 2: Pain at rest
• Stage 3: Necrosis or gangrene.
The pain of intermittent claudication occurs with walking and is relieved to suspend. The most frequent location is the same level of the calves, but may be present in other areas, indicating the area of \u200b\u200bvascular compromise.
rest pain indicates a greater severity of ischemia. Occurs when the patient takes the horizontal position and is relieved somewhat by sitting.
Gangrene is the ultimate expression of arterial insufficiency. Usual absence of hairiness in the skin and sometimes in the fingers, if ischemia is atrophic skin, thin and pale, there is decrease in nail growth, there is a decrease in skin temperature and absence of pulses peripherals.
nervous system complications
neural damage in diabetes mellitus may be due to ischemic or exposure of neurons to a high concentration of glucose or abnormal metabolites thereof (sorbitol and fructose) that cause chemical changes in nerves and impairs the ability of nerves to transmit signals.
They also have the potential to damage blood vessels that carry oxygen and nutrients to the nerves.
some genetic traits also may make some people more susceptible to nerve disease than others.
People with diabetes can develop nerve problems at any time, but significant clinical neuropathy can develop within the first 10 years after receiving the diagnógtico
The risk of developing neuropathy increases the longer a person who has had diabetes. About 60% of people with diabetes have some form of neuropathy.
types
common diabetic neuropathy Peripheral neuropathy
:
is neuropathy that affects nerves in the extremities (feet, legs, arms and hands) which may be sensory or motor.
sensory neuropathy is the most common, usually bilateral, distal, symmetric, slowly and gradually. Severe cramping that is worse at night, numbness and sometimes pain is severe and accompanied by hyperesthesia, to the extent that the patient can not tolerate the touch of the sheets
vibratory sense loss is a symptom earliest. There is a decrease or abolition of the sensitivity proprioceptive.
The hypoesthesia permit a late injury are advised for patients.
Motor neuropathy causes muscle atrophy and hypotrophy mainly of the interosseous and lumbrical. This produces a change in the points of the foot causing hyperkeratosis, joint dislocations and deformities of the foot. The review notes the patient's inability to separate the fingers together (a sign of pathological range), decreased or absent reflexes, especially aquileanos.
perforans Evil is a common complication is chronic ulceration, sometimes profound painless, which usually sits at the points of support (plantar surface of the first through fifth metatarsal or heel dig). It is produced by oppression settled by the departure areas and bad hypoaesthesic trophism and leads to infection of the subcutaneous tissue.
Autonomic neuropathy:
is neuropathy that affects nerves that serve internal organs, processes and systems of the heart, gastrointestinal tract, sexual organs, urinary tract and sweat glands. Symptoms include:
• Incontinence • Digestive problems (diarrhea, constipation)
• low blood pressure
• Dizziness • Fainting
• The inability to feel pain
• Excessive sweating • Impotence
focal neuropathy:
neuropathy is affecting a specific nerve and part of the body, such as facial muscles hearing, pelvis and lower back, thighs and abdomen. Symptoms include:
• Earache • Severe pain in the lower back or pelvis
• Pain in the chest, stomach
• Pain or discomfort behind the eye
• Inability to focus eyes
• Vision Double
• Paralysis on one side of the face
• Hearing problems
Diagnosis of neuropathy
addition to obtaining your complete medical history and physical examination, you can review:
• Muscle strength • muscular reflexes
• The muscle sensitivity, position, vibration, temperature and light touch.
You can perform the following tests:
• nerve conduction studies (to check flow of electrical current through a nerve)
• electromyography (to determine how muscles respond to electrical impulses)
•
nerve biopsy
principle of treatment of diabetes mellitus
Although no firm evidence to show that the adequate glycemic control reduces complications in elderly patients, rigid metabolic control can prevent dehydration, obesity, and polyuria. It is necessary to carefully review treatment plans with patients and their caregivers. When developing a treatment plan is necessary to consider many factors, including visual acuity, renal function, cognitive and functional status and support systems.
The 2 main objectives of the treatment of diabetes in people elderly is to prevent complications and preserve function.
modifications of diet and lifestyle, as exercise and weight reduction, can control blood glucose levels in more than one third of elderly patients with type II diabetes.
Physical Activity
Warming:
are needed to prepare the body for physical activity. Perform functions to prevent injuries and improve physical performance. When the body is at rest, blood flow to muscles is relatively slow and small blood vessels are closed. With activity, blood flow increases as the vessels are opened and prepare the muscles for the work they will perform.
physical activity to increase energy production increases the temperature of the muscles, improving coordination and reduces the likelihood of injury.
warming should begin with movements of large muscle groups to produce a large inflow of blood. Later they activate specific muscle groups. It is necessary to warm up before a workout so that there is a greater physical performance.
Stretching:
After a good warm up to stretch can allow us muscles remain flexible according to the degree of muscle tension for each person.
is important to know the reasons why we need to stretch our patients:
• reduce muscle tension and allows us to relax the body
• Improve coordination of movements
• Increase the possibility of movement • Improve and streamline
circulation
we realize Stretching before and after our exercise plan, also during the day and allows us to relieve muscle tension.
The proper way to stretch our muscles are
• With a voltage relaxed and maintained, making sure the muscles are stretched. Avoiding rebound or pain.
• A slow breathing, rhythmic and controlled breathing naturally and if the position it prevents decrease muscle tension.
• The right time to stretch is 15 to 30 minutes.
We must also take into account the stretch reflex of muscles which are protected where ever there is an overstretching of muscle fibers by a sudden movement or forced displayed a nervous reflex that causes muscles to contract. It is a defense mechanism of the muscles to avoid injury. Therefore, if we force too much to do these stretches, the effect is the opposite of that intended. OSTEOARTHRITIS
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