TYPE-2 DIABETES MANAGEMENT IN ELDERLY

Introduction

The presence of type-2 diabetes is a condition in which the individual’s body is unable to produce enough amount of insulin or the cells in the body becomes incapable to use insulin for supporting the effective functioning of the body (Roden and Shulman, 2019). There are many factors that leads to the development of type-2 diabetes such as physical inactivity, increased body weight, obesity, family history of diabetes and others (Chatterjee et al., 2017). The pathophysiology of type-2 diabetes inform that it is mainly raised due to the dysfunction of the pancreatic β-cell that is responsible for producing insulin and the lack of insulin intake by the target organs of the boy for using it. This results in abnormal control of blood glucose as failure to use insulin by the organs makes them incapable to convert glucose into energy to be used in the body leading to the development of type-2 diabetes (Roden and Shulman, 2019). The presence of type-2 diabetes increases the risk of development of heart disease, high blood pressure, stroke and others in individuals which leads to fatal consequences and hindered well-being of people (Kenny and Abel, 2019). Thus, in this research, the pharmacological and Non-pharmacological intervention taken for management of type-2 diabetes is to be discussed to promote better health and well-being of individuals affected by the disease. For this purpose, a detailed literature review is to be presented regarding the topic.

Research Question

The research question is significant to be present because it defines the key aspects been focused in the study to be examined and the outcome of interest which influence the steps to be followed in executed in the study (Mirtha and Permatahati, 2018). In framing the research question in the study, the PICO framework is to be used. This is because PICO delineates the target population along with other key elements in the study which are mainly to be focussed and present in formulating a well-defined research question (Cohen et al., 2017). The PICO stands for population, intervention, comparison and outcome. The population to be focussed in the study is elderly individuals who are affected by type-2 diabetes. The intervention in the study is non-pharmacological and pharmacological management strategies of type-2 diabetes. There are no comparing variables present in the study and the outcome focussed in better well-being and health of the elderly with type-2 diabetes.

Population= Elderly of 65 and overage

Intervention= Pharmacological and Non-pharmacological management

Comparison= No

Outcome= Effective management of type-2 diabetes in elderly

Thus, the research question is: What are the pharmacological and non-pharmacological interventions for effective management of type-2 diabetes in elderly?

Aim

The study aims to determine the pharmacological and non-pharmacological interventions for effective management of type-2 diabetes in elderly.

Rationale of the Study

In the UK, diabetes is one of the common metabolic long-term health issues faced by the elderly. It is evident as half of the people who are suffering from diabetes in the UK are aged 65 years and over and quarter of them are aged 75 year and over. This equals to 10% of the people aged 75 tear and over and 14% of people aged 85 years and over in the UK to be suffering from diabetes (BCGS, 2018). There are no specific figures which indicates the rate of presence of type- and type-2 diabetes but it is been mentioned that 90% of the elderly who have diabetes are suffering from type-2 diabetes with rest 10% suffering from type-1 diabetes (diabetes.org.uk, 2020). It is also predicted that currently 2.7 million adults and elderly are suffering from diabetes in the UK which is going to be raised to 5 million by 2025 (diabetes.co.uk, 2019; diabetes.org.uk, 2020). Thus, it indicates that the prevalence of type-2 diabetes is high in case of elderly in the UK and it would lead to affect more older people in the coming years.

The type-2 diabetes among the elderly is an issue because it contributes to increased mortality among them (Wright et al., 2017). This is evident from the study of Wright et al. (2017) where it is mentioned that the crude mortality rate due to type-2 diabetes in the UK among the elderly is 42.7/1,000 person-years whereas the mortality rate among the elderly without diabetes is 19.5/1,000 person-years. It indicates that the life expectancy of the elderly is reduced as a result of suffering from uncontrolled type-2 diabetes. As argued by Fried and Carlton (2018), presence of type-2 diabetes causes damage to the blood vessels as a result of supporting high blood pressure in the body. The high blood pressure causes the blood to move under pressure that damages the arteries leading to hindered flow of blood to the heart and contributing to development of heart disease (Fried and Carlton, 2018).

The presence of type-2 diabetes in the elderly is currently an issue because it is mentioned to cause reduction of life expectancy in elderly by 10 years (diabetes.org.uk, 2020). Moreover, the presence of type-2 diabetes in elderly has been currently found to be responsible to increase five times suffering from coronary heart disease and three times higher suffering from stroke compared to normal individuals (diabetes.org.uk, 2020). Thus, it can be seen that type-2 diabetes in elderly is worsening their condition with progressing year and making them face increased risk of additional health issues. Therefore, the current study is important so that the way management of type-2 diabetes in elderly is to be made can be understood to limit it prevalence and worsened impact on the health of the individuals.

Methodology and Research Design

The research methodology specifies the techniques and procedures used for identifying, selecting, processing and analysing information regarding any study topic. It allows to critically evaluate the validity and reliability of the study by the reader (Gibson, 2017). In this study, the mixed methodology is to be followed according to which qualitative and quantitative method are to be included. The quantitative research methodology is to be followed because it provides information about the statistical data regarding any study topic which assist in generating better knolwdege and understanding of the facts (Apuke, 2017). The qualitative research methodology is to be followed in the study because they lead to contain interpretation of the verbal data of the participants which provides better scope in understand the explained data in the study (Mohajan, 2018).

The electronic data search strategy is been executed to gather information regarding the study because it is cost-effective, less time consuming and more accurate in presenting and identifying required data (Eriksen and Frandsen, 2018). The electronic database to be used in gathering information are CHINHAL, Medline and Google Scholar. The specific databases are to be used as they contain articles and journals regarding various medical topics from a national and international context. On the basis of the research question, the search is been execute in the databases by using keyword such as “type-2 diabetes management”, “older people”, “medicine for type-2 diabetes” and others. The search led many articles to be identified and initially nearly 2367 articles are identified which after screening was reduced to 150 articles because the others were rejected due to being duplicated, having data error and less relevance in covering the study topic. The further analysis of the articles led nearly 85 articles to be excluded due to irrelevance and it led 65 articles to be considered. On following inclusion and exclusion criteria, finally 8 articles were considered in framing the literature review.

The inclusion and exclusion criteria followed for ensuring validation, consistency and robustness in the study are as follows:

Inclusion criteria: The articles published between 2013 to 2020 are considered for inclusion as they contain most validated data which are supported by current experimental information and research to be logically analysed in understanding their true meaning and present them in enhanced manner in the review. The primary studies containing qualitative and quantitative data are included as they help in presenting numerical data to inform the usefulness of each management strategy for the type-2 diabetes in elderly apart from explaining their way of delivery in caring for the elderly. The articles related with type-2 diabetes management for elderly is to be included along with those that are fully accessible, written in English and academic in nature.

Exclusion criteria: The articles that are published before 2013, not fully accessible, not written in English, contains data of type-2 diabetes regarding children and adults, non-academic and only abstract is available.

Quality Appraisal

The quality appraisal of the eight selected articles in this literature review is performed by critically and cautiously examining them while identifying their strength and weakness, robustness, validity, reliability and research methods been used. The initial analysis of the eight articles were executed carefully and the initial results revealed they expresses minimal bias in methodological aspect due to which different scale is considered in better analysis of each of the article. The critical appraisal of the articles is made by using the critique tool known as Caldwell’s Critical Appraisal checklist. The specific tool is been used as it contains set of question that allows systematic analysis of each aspect of the articles to effectively appraise them and determine their validity for inclusion in the study (Caldwell et al., 2005). The Caldwell’s Critical Appraisal checklist is used in determining the best quality studies and a Likert Scale is been formed to value each article according to which Y for yes = 2, P for partially = 1 and N for No = 0 (Caldwell et al., 2005) (Appendix 2). A data extraction sheet is been used in ensuring that each of the articles was related and relevant to the raised research question (Appendix 3). The data extraction sheet is beneficial because it helps to effectively summarise the key findings and results from all the articles in a collaborative manner and synthesise data from them to consolidate the result validity in the study.

Ranking

The eight selected articles are ranked on the basis of analysis by the Caldwell’s Critical Appraisal Tool. Among the eight articles, seven of them followed quantitative research and one of them followed qualities research and ensured presentation of data in statistical and explanatory format. The ranking system of the articles revealed that most of them were of high-quality and expressed high validity with the study topic (Appendix 2). Among the studies, 2 articles presented the impact of Metformin use for type-2 diabetes management in elderly (Tizazu et al., 2019; Aggrawal et al., 2017). The other 3 articles presented the impact of differential delivery of insulin therapy for management of type-2 diabetes in elderly (Dalal et al., 2017; Rayman, 2017; Sullivan et al., 2018). The last 3 articles highlighted the impact of aerobic exercise as non-pharmacological intervention in management of type-2 diabetes among the elderly (Dixit et al., 2017; Kim et al., 2018, Rahbar et al., 2017).

Summary and synthesis of articles

The eight articles identified in the study provided detailed highlight about the pharmacological and non-pharmacological intervention for type-2 diabetes management in elderly. Most of the research process used in the studies were able to be determined and the critical analysis tool is used in apprising each of the methods.

Title

The Caldwell’s critical appraisal tool mentions to determine the appropriateness of the title of the study (Caldwell et al., 2005). This is because presence of well-defined title in the study that precisely and accurately present idea regarding the topic of the research helps in understating the key aspects of the study. Moreover, title is the main part of the article which is read by most people to initially determine the focus of the study (Caldwell et al., 2005). In all the eight studies, it is seen that the researchers have presented well-defined title of the study topic they are covering, and all these titles are seen to be presented in relation to the research question. This aspect of all the studies assisted to find which articles are specifying pharmacological management information (Tizazu et al., 2019; Aggrawal et al., 2017; Dalal et al., 2017; Rayman, 2017; Sullivan et al., 2018) and which of them are mentioning non-pharmacological management (Dixit et al., 2017; Kim et al., 2018, Rahbar et al., 2017) of type-2 diabetis in elderly without requiring in-depth reading of the articles that saved time and energy to be used for their later analysis of results to be presented in the study.

Credibility of Authors

The credibility of the authors in the research are to be identified so that it can be ensured that studies are performed by well-qualified and potential research personals those have in-depth knowledge regarding the study topic (Caldwell et al., 2005). In six of the eight studies, the professional qualification and titles of the researchers involved in framing the study was provided in detail and each of the authors are found to be Ph.D holders with placed as lecturers in eminent colleges (Tizazu et al., 2019; Aggrawal et al., 2017; Rayman, 2017; Sullivan et al., 2018; Kim et al., 2018, Rahbar et al., 2017). However, the two studies Dixit et al., 2017 and Dalal et al., 2017 were found not to present the detailed qualification of the authors but the studies mentioned that information in the articles are addressed through the help of authorised personals of universities which indicates that professionalism is been maintained in them.

Abstract

The Caldwell critical appraisal tool mentions to determine if the study has presented well-defined abstract and mentioned the hypothesis developed in the studies (Caldwell et al., 2005). All eight studies are found to have well-presented abstract. The presence of abstract is important because it acts as summary to guide the reader regarding the way topic is been covered in the study and allows the reader to initiate forming opinion regarding the research (Caldwell et al., 2005). In all of the studies, the experimental hypothesis is been presented and all the eight studies mentioned the key variables at the initiation stage to be followed in framing the research. The presence of well-defined hypothesis led to determine the link between the theory with the research question in enhanced way and helped to determine validity of the data.

Methodology

In seven of articles, the quantitative methodology has been used whereas in one article only qualitative methodology is been used. The benefit of using quantitative methodology in the studies is that it allowed presentation of data in objective manner and with increased validity (Rutberg and Bouikidis, 2018). Moreover, the qualitative data would help to explore in-depth regarding the facts presented in quantitative format. The population in the studies are required to be identified so that it can be ensured that the type and number of participants present in the study are relevant and appropriately related with the study topic (Queirós et al., 2017). In all the eight studies, detailed information about the population involved in them are presented.

Critical Appraisal of 6 Studies

The careful review of eight of the articles led to identify that six of them were to be included for critical appraisal in the literature review. Thus, the article by Tizazu et al., 2019; Aggrawal et al., 2017; Rayman, 2017; Kim et al., 2018, Rahbar et al., 2017 and Dalal et al., 2017 are to be included for appraisal in the study. This is because these six studies scored the highest among the eight articles chosen for final inclusion in the study as evident from the ranking mentioned in the data extraction table. In the chosen six articles, the title was concise and clarified along with it incorporated all the mentioned components in the PICO framework. In these studies, the qualification and professional titles of the researchers of the articles were presented in clarified and significant manner which led to support credibility of the studies as it ensured the study is done professionally and methodologically by qualified people. The keywords in the articles were in detail and the abstract mentioned in each of the articles were clarified and methodological as they included background, aim/objectives, methods, results and conclusion.

Among the studies, four of the six studies were ethically approved by ethics committee which ensured the studies were performed morally and without ethical violation. The study by Tizazu et al. (2019) was approved by the National University of Singapore Institutional Review Board, Aggrawal et al. (2017) by Institutional Review Board/Independent Ethics Committee, Rayman et al. (2017) by East of England Central Cambridge Ethics Committee and Rahbar et al. (2017) by ethics committee of Shahid Beheshti University of Medical Sciences. The studies by Dalal et al. (2017) and Kim et al. (2018) though did not mentioned any specific approval by ethics committee but it mentioned no individuals were harmed in the study and appropriate consent were taken ensuring ethical consideration is been maintained in them. All the six articles highlighted gaps present in the literature and reason for execution of the study which ensures each of them mentioned rationale behind execution of the studies.

In the review, it was seen that six of the studies used randomised cohort-controlled trial as the research design. This led in each of the studies to determine the cause-and -effect relationship of the treatment been suggested for management of type-2 diabetes in elderly patients. All the five studies that were quantitative used tables and figures and one qualitative study used verbal interpretation in presenting the data in valid form and used contrasting studies to support the argument developed ensuring reliability of the studies as the facts presented are proved through cross-reference. The results and find in all the six articles were presented in effective form by clearly linking with the conclusion of the study. A clarified discussion is reached in all the studies.

All the six articles highlighted the strategies that can be used in managing and controlling prevalence of type-2 diabetes in elderly patients. The studies by Tizazu et al. (2019) and Aggrawal et al. (2017) highlighted the specific medication to be used in managing type-2 diabetes in elderly. However, the articles Dalal et al. (2017) and Rayman et al. (2017) added the nature and level of closed-loop insulin therapy to be followed in managing type-2 diabetes in elderly affected by the disease. In contrast, the studies by Rahbar et al. (2017) and Kim et al. (2018) focussed to mention the impact of aerobic exercise as non-pharmacological intervention to be followed in managing type-2 diabetes in elderly. The analysis of the facts in the six studies led to formation of key themes which are as follows:

Theme 1: Impact of Metformin in management of type-2 diabetes in elderly

The articles by articles by Tizazu et al. (2019) and Aggrawal et al. (2017) are re;eavnt in explaining the theme as they focused on the impact of use of the metformin in type-2 diabetic elderly. According to Tizazu et al. (2019), aging leads to development of type-2 diabetes and related disorder such as diabetic-associated inflammation. The diabetes-associated inflammation results the body to develop increased insulin resistance and worsening of health condition for diabetes. The study highlighted that after reviewing 3270 elderly diabetic patients, the researchers identified presence of TIMP-, sTNFRll and sICAM-1 in higher number in people with diabetes led them to be further develop worsen insulin resistance. The comparison of the use of monotherapy of Metformin and Glipizide in managing inflammation and type-2 diabetes in elderly mentioned that Metformin monotherapy expressed greater significance (P 0.05) compared to other monotherapies in controlling diabetes-associated inflammation and control of type-2 diabetes in people. Thus, the study highlighted which of the medication therapies (Metformin or glipizide) could be more effective in reducing health risk and enhance health regarding type-2 diabetes in elderly. In contrast, the study by Aggarwal et al. (2017) highlighted the which form of medication (Metformin) release that are immediate-release or extended-release would be safer and more effective in managing type-2 diabetes. The immediate-release (IR) of Metformin is the process in which the medication in administered through meal for several times of the day and the extended-release (XR) is administration of Metformin in formation once a day to support blood glucose control. The review of 539 patients for 24 weeks in the study revealed that HbA1c level (−24.7 (XR) vs −27.1 (IR) mg/dL) were similarly controlled in patients who were provided immediate-release metformin as well as extended-release Metformin.

Theme 2: Impact of Insulin therapy for the management of type-2 diabetes in elderly

The study by Rayman et al. (2017) highlighted the impact of closed-loop insulin delivery compared to subcutaneous insulin therapy in type-2 diabetic elderly patients in the general ward. The researcher for the purpose included 40 patients and randomly assigned to control group and closed-loop intervention group. The result revealed that the target blood glucose level in reached in 59·8% of patients in the experimental group with closed-loop insulin therapy compared to 38·1% individual in the control group receiving normal insulin therapy. This indicates that closed-loop delivery of insulin without the meal-time boluses are effective and safe in enhanced management of type-2 diabetes in elderly patients. In contrast, the study by Dala et al. (2017) identified in which condition the insulin therapy may not work in management type-2 diabetes in elderly. The study by analysing 55,608 patients identified that 4.5% of them develop hypoglycaemia min use of basal insulin therapy. The patient who developed hypoglycaemia discontinued the use of insulin therapy in management of type-2 diabetes which worsened their health condition. This indicates that blood glucose level in type-2 diabetes elderly is successfully managed by use of closed-loop insulin and basal insulin therapy if it does causes hypoglycaemia development in patients within 6 months.

Theme 3: Impact of aerobic exercise for management of type-2 diabetes in elderly

The study by Rahbar et al. (2017) mentioned that aerobic exercise helps in resolving metabolic disorder of the elderly which improves their body metabolism to fight insulin deficiency, performance or both. The analysis of 30 elderly patient who were involved in aerobic exercise revealed that significant reduction in their fasting blood glucose, glycosylated Haemoglobin and others were experienced in the experimental group compared to the control group. This indicates that aerobic exercise is effective in controlling type-2 diabetes in elderly patients. The similar aspect I also focussed in the study by Kim et al. (2018) where impact of aerobic exercise in combination with outdoor exercise is analysed in regard to management of tyeop-2 diabetes. The results revealed that significant reduction of the level of chemerin and insulin level in the blood was seen among the type-2 diabetic patients. This revealed that exercise is effective in management of type-2 diabetes in elderly as well as adult patients.

Conclusion

The key purpose of the current literature review is to identify pharmacological and non-pharmacological intervention to be used in managing type-2 diabetes in elderly. This includes highlighting the medication, treatment therapy and physical exercise to be used and applicable in enhanced management of type-2 diabetes in elderly. A total of 8 articles been selected in framing the review and two of them mentioned use of Metformin monotherapy as effective intervention for managing type-2 diabetes. One of the articles mentioned use of closed-loop insulin therapy and another mentioned basal insulin therapy if hypoglycaemia does not develop within 6 months of administration in elderly patients to be effective in management of type-2 diabetes in individuals. Two studies highlighted use of aerobic exercise to be effective way of better management of type-2 diabetes in elderly who are affected as well as not affected by the disease.

The article by Rayman et al. (2017) mentioned closed-loop insulin to be used in type-2 diabetes management in affected elderly patients. This is because successfully reduces mean glucose level that are raised in diabetes along with lower the time spent in controlling hypoglycaemia caused in basal insulin administration. It is also mentioned to be used as it reduces the complexity of regulation of glucose level in the blood and risk of hypoglycaemia that may be caused by delayed or skipped meals in elderly. In contrast, the study by Tizazu et al. (2019) indicated that metformin monotherapy is preferred to be used over glipizide monotherapy and other pharmacological therapies. This is because they help in reduction of inflammatory responses in the body associated with diabetes which are raised due to uncontrolled diabetes and worsening the health condition of the elderly as well as adults affected by the type-2 diabetes. Moreover, the metformin monotherapy is to be used for type-2 diabetes management in the elderly as it reduces the mortality risk of the patients due to the disease, in turn, supporting them to have enhanced life expectancy. The studies by Rahbar et al. (2017) and Kim et al. (2018) mentioned use of aerobic exercise to be made in management of type-2 diabetes in elderly. This is because the exercise leads to enhance the metabolism of the body which makes the individual become able to effective use insulin in the body and overcome insulin resistance with gradual effect to most extent. However, they are to be delivered in association with medication or pharmacological therapies to ensure getting best results.

In summary, to manage type-2 diabetes in elderly inclusion of both pharmacological and non-pharmacological intervention is to be made to develop better control of the health condition. The aerobic exercise is to be holistically supported and assisted to be performed in diabetic as well as non-diabetic elderly to ensure prevention and better management of type2 diabetes among elderly.

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Appendix 3: