This is a state of disillusion, frustration and a meek submission to diabetes which results in complete disregard to blood sugar level management. This is regarded as “freedom” from this confusing , frustrating and ever demanding condition. This is often seen many years after commencement of treatment.
This burnout is usually accompanied by varying levels of stress, anxiety, depression and labile emotions.
- Scared of living with diabetes
- uncomfortable social situations- cannot swim, cannot party, cannot be out for late night meetings, cannot do this or that…
- overwhelmed and angry with diabetes
- feeling “alone”
- Feeling diabetes is taking too much of mental and physical energy
- Food deprivation
- concerns about the future- “Can I marry?”, “Will I be able to conceive or have a normal sexual life”, “How long can I live?”
The commonest modes of presenting can be:
- Self destructive behavior
- Eating or drinking whatever one wants knowing fully well it is not good for those with diabetes.
- Improper insulin shots or lying about medicine intake
- Improper maintenance of log books
- Fabricating glucometer readings
- Complications of diabetes can set in which in turn makes things worse to a point of suicidal behavior.
How to overcome a burnout?
- Stay focused and motivated. Do not attempt to be perfect- forgive those occasional high sugar levels if other readings are fine.
- Identify barriers to care of diabetes and resolve them.
- Edit negative thoughts
- Enroll into support groups
- Speak with a friend or health care professional
- Rethink exercise schedule
- take a break
- Laugh it off
A check list:
Ask yourself whether you have done the following:
• Enough medicines are there with you.
• Have you had the blood tests for cholesterol, liver, kidney, hemoglobin , urine for protein, sugar and 3 month average of sugar at least once in the past 6 months.
• Have you had a foot check , an eye check by eye doctor and a heart check such as having an ECHO cardiogram and Treadmill test in the past one year. There are instances when the treadmill could not be done due either being overweight or having knee or back problems.
• If an elderly male, have you had a PSA test done in the past one year ( this is a blood test for the prostate) Alternatively, you could meet with a Urologist, the specialist for these problems.
• If an elderly male or female, have you had the calcium, vitamin D levels checked in the past year and a bone mineral density which is a scan for the bones showing if they are prone for fractures. Vitamin D levels, if very low, will need a correction with medicines and a recheck done depending on the doctors advice.
• Women after the age of menopause or those with a strong family history of cancer of the breast should have a mammogram ( special X ray of the breast) done once yearly.
• Thyroid levels can be checked yearly once , unless on treatment.
• Distended abdomen, “gaseous feeling” and belching with a mild upper chest discomfort can sometimes be a marker for something sinister. Have a gastroscopy done to make sure there are no ulcers.
• All bleeding from below is not from ‘piles”. It may also be worthwhile to have a colonoscopy done.
• Have you been monitoring your progress and if you can see no improvement in either the sugar levels or weight, you must seriously reconsider your options. Please do not always find fault with the doctor or the medicines, the reason could be elsewhere.
• Have you got the glucometer serviced or checked out especially if more than an year old
• Have you shown the Insulin delivery devise to the doctor once a year if the refilled pens are being used. Faulty devices can lead to errors in dosing.
• All said and done, there is no point in doing an annual whole body scan to make sure all is well. There are so many things which may go unnoticed and also will be risk of too much of radiation.
• Please check the footwear daily for wearing out or foreign bodies. They can prevent serious mishaps later.
• Have you had an annual Flu vaccine? This will reduce the flu which occurs while traveling a lot
• For those above 65 years of age a pneumococcal vaccine is useful. This is to be taken just once in a lifetime.
Once we are born, we all have to die someday. During the course of our life, we learn a lot from our experiences, sometimes we do not. We all wish to live longer and age gracefully. You may recollect that our grandparents lived longer and healthier. This is largely due to reduced stress levels, natural unprocessed food, more of physical activity and less dependent on automated gadgets or electronic gadgets.
Ironically, people of today look for shortcuts to everything for example weight reduction surgery, face lift surgeries various plastic surgical techniques to help beat natural aging and also gadgets which can remotely control everything in life from opening the gates, switching on the lights, locking the house and what not. Who knows, maybe in the near future we may even have drive in hospitals where you drive into the OPD room, speak out your symptoms into a machine , get a token, have blood drawn for tests and have the doctor give the medicines at another counter.( like as in Mc Donalds drive through)
Life has indeed become so fast, we hardly have the time to stop and think of ourselves. There are so many age defying cosmetics flooding the market these days.
Many people with diabetes live to a ripe age by leading a healthy lifestyle and regular check. However, some are lucky not to have diabetes until their middle years, but become diabetic after 65 years or more. In a study around 7% of the older adults were diagnosed as having diabetes by noting high fasting sugar, whereas 6% were diagnosed based on their post meal sugar levels.
Common changes with advancing age
Glucose intolerance increases and slowing of the glucose absorption occurs with advancing age. There is a decline in lean body mass, there may be an increase in body fat due to increasing insulin resistance. There may be a decline in level of physical activity.
The medicines that were once doing well in controlling sugar levels may not work as effective as age advances.
Older adults may not perceive hunger and may not feel thirsty as well. Digestion becomes delayed. Bowel habits may not be regular as before. Skin may become dry. The response to low sugar levels are much slower as age advances. Low sugar levels may manifest as confusion and dizziness. Tremors and sweating are not common.
- Reduced vision, reduced mobility and memory loss is also common. Mistakes while dosing the medicines are also common.
- Complication of the eye, nerve and kidney is directly linked to the level of sugar control. Maintaining good levels can delay the onset or progression of the above complications.
- However, heart diseases stroke, and blood vessel problems are directly linked to the control of blood pressure and cholesterol panel. This is one reason why doctors prescribe medicines for cholesterol even when the levels are normal.
- With advancing age, any of the above complications are possible. The recovery from the complications will not be as smooth as when coming at a younger age.
- Some need assistance while walking such as a physical support or a walking stick. The floor in most of the places has a smooth surface and planting the feet is quite a hazard.
- Most of the time, older adults feel embarrassed to address their fears to their dependents. They may feel better to mention those to their healthcare providers. This is quite normal
There are not many studies involving older adults. However, based on some of the studies, the following are applicable:
- Sugar levels between 7 to 8.5 mmol/L is acceptable
- Blood pressure ≤ 140/80 mm Hg
- Total cholesterol ≤ 5.2 mmol/L
- HbA1C ( the three month average of sugar ) is not reliable in older adults as red cell span may be reduced with advancing age. Diseases of the kidney and liver may affect the value.
However, the levels of blood sugar and 3 month average are not to be as stringent as for that of a younger person.
Increase in urine output may be due to urinary bladder irritation or dysfunction, medications for reducing blood pressure or due to prostate enlargement in males and not always due to high blood sugar levels.
Low sugar levels can mimic having a fit or stroke.
- The check up for the older adults must be more regular and frequent. The annual eye, heart check and foot check may have to be done more frequently if there are minor problems.
- Assessment of the kidney function is made by blood tests which may show changes. This can be tackled if checked for.
- Care of the feet may need heel protection, extra cushioning of wheel chair of bedding and prevention of dry skin is important.
- Driving at this age may be troublesome due to the reduced vision, reduced judgment and reflexes.
- Have the calcium, vitamin D levels checked as well as the bone mineral density. Older men have to be assessed for prostate as well.
- Make sure the older patient above 65 years must have taken a vaccination against pneumonia once and a vaccine against flu yearly.
- Many of the older adults may be having medicine such as diuretics ( which increase urination), hormones such for post menopause or steroids , and anti depressants which may worsen sugar control.
- Maintain good oral hygiene, check the feet, the skin folds for fungal rashes and boils which may go unnoticed by the patients.
- Make sure the bowels move once a day as constipation is very common.
The consultation with the health care professional:
- It will be useful if a small handbook can be used for mentioning their concerns as they may forget during the consultation.
- Maintaining a log book of the sugar readings and a diary of food intake will help to make inferences and plan management.
- The consultation can take more time than normal making the patient understand what is expected.
- The waiting period can be a problem as well. It will be worthwhile to have the blood and urine samples drawn early and they can have a light snack while waiting for their turn.
- Most of these adults are on many medicines and so may have gastritis.
- It is worthwhile to have a check by Gastroscopy ( a tube inserted through mouth to see if any ulcers in the stomach) or colonoscopy( tube inserted through anus to look for any problems down below)
- It sure pays to empathize with the elderly. They need the love and attention.
- Exercises in this age group are to be carefully planned.
- For those with eye problems or after laser treatment, it is advised to avoid intense exercises which may further increase the pressure.
- For those with neuropathy, it is advisable to perform exercises such as walking or cycling. Be careful of weight lifting.
- Jogging and swimming can be done if they have been doing the same routine over the years.
- However, get the doctors advice and clearance before planning a regime.
- Any exercise in water is useful and safe for the joints. It helps to burn calories as well.
- Walking together in groups or even performing aerobics, Yoga or Tai Chi also help in a better way as combining enjoyment with exercises make this pleasurable and motivated to continue with this. Yoga, meditation also help in relaxation.
The aims of management:
- The management of older adults involves avoiding low sugar levels, avoiding weight gain or loss in excess and to maintain well being.
- Metformin, gliclazide, Vildagliptin and Sitagliptin are safe to use among the oral medicines.
- Insulin is safe if used sensibly. The advent of pen devices has helped the patient care. It allows accurate dosing and gives audible clicks while dialing the dose. Using the bottle of insulin and syringe may be clumsy at times and can give erroneous dosing which can be quite a headache.
- It is better to have simple treatment plans rather than complex regimes difficult to remember.
- The patient care given, the patient care giver, the patient care process and the patient care outcome are very important in the management of this elder population.