Case Study Type 2 Diabetes 1

CASE STUDY: TYPE 2 DIABETES

By[Name]

Course

Institution

Location of institution

Professor’s Name

Date
 Case Study Type 2 Diabetes 2

Introduction

The case study involves Jack, a 76-year old-man presenting to the facility with

complaints that he has not been feeling well for the past few days. Jack has a 7-year history of

type two diabetes, and also he was recently diagnosed with hypertension. In addition, he is also

obese, with a BMI of 37.3. Jack has been on metformin and Glicazide since he was diagnosed

with diabetes type. The patient fasting laboratory tests indicated HbA1c 10% with 86mmol/mol,

Glucose 230mg/dL, his blood pressure was 145/93 mmHg. In the past few months, the patient

has experienced an increase in weight since his physical activity has reduced as he was also

diagnosed with arthritis which makes it hard for him to perform tasks that require frequent

movement of his joints. The patient takes his blood glucose levels daily, and over the past one

week, he has witnessed a sharp increase in the readings before suddenly starting to feel unwell.

At first, he ignored the changes in blood glucose, hoping to get better, but it became worse every

day, prompting him to visit the facility for further checkups and medical advice. In addition, the

patient also experiences neuropathy symptoms affecting his lower limbs which at times impairs

his movement given that he was also diagnosed with arthritis a few years ago. Jack stays with

his wife who has also been diagnosed with dementia, and therefore he has to take care of her as

she is now dependent. Their children are all staying in other countries, and visit them once a

year, and therefore it means they spend most of the time alone.

Diabetes Type 2

Diabetes type 2 is one of the common metabolic disorders prevalent in older adults. The

disorder is caused by a combination of two factors which include the inability of the insulin-

sensitive tissues to respond to insulin, and defective insulin secretion by pancreatic B-cells.

According to Galicia-Garcia et al. (2020), T2DM accounts for 90% of the total diagnosed cases
 Case Study Type 2 Diabetes 3

of diabetes whereby T1DM accounts for approximately 10% of the total cases. T2DM is closely

linked to obesity, inactivity and high blood pressure. There has been a sharp increase in the

prevalence rate of T2DM in the world which is closely linked to the high number of the ageing

population. Older adults experience changes in glucose homeostasis hence increasing the risk of

developing T2DM (Gao et al., 2020). also, obesity among older adults is increasing which is also

a great risk factor for T2DM, and most of them do not engage in physical activity making them

more vulnerable.

The B-cells are responsible for insulin production which is synthesized as pre-proinsulin.

In the production process, the pre-proinsulin goes through the process of conformational

modification which takes place in the endoplasmic reticulum (ER) to produce proinsulin. The

pro-insulin is later translocated to the Golgi apparatus where they are cleaved into C-peptide and

Insulin (Lee and Halter, 2017). The insulin is stored in the granules for use when needed. Insulin

release from the granules is triggered by high glucose concentration in the blood. Dysfunction of

the B-cells either through toxic pressure, inflammation or oxidative stress among others (Galicia-

Garcia et al., 2020). a dysfunction in the B-cells hinders the production of insulin, and thus the

body is unable to regulate the glucose levels in the blood.

Biopsychosocial Impact of T2DM

T2DM leads to microvascular conditions which impact a person's quality of life. Some of

the complications a person with diabetes may experience include retinopathy, and neuropathy.

According to Su et al., (2018), neuropathy can lead to a lot of pain in the patient as it involves

the damaging of one or several nerves due to the uncontrolled glucose level in the blood. A

person with neuropathy due to T2DM may not be able to engage in physical activity, and at

times they become dependent on the people close to them. in the case of Jack, he only stays with
 Case Study Type 2 Diabetes 4

his wife who is also incapacitated due to dementia. T2DM with presenting symptoms of

neuropathy is likely to affect their overall quality of life since Jack will not be able to attend to

himself, and also his wife. Also, elderly people with diabetes are at risk of sarcopenia which is

due to the increased rate of muscle loss associated with old age (Bulut et al., 2017). Sarcopenia

increases frailty hence one is at an increased chance of falls which may lead to fractures

(International Diabetes Federation, 2017). Falls among elderly people is both a biological and

social issue that may need addressing by both medical professionals and home caregivers. For

instance, at home, the caregiver can ensure that the elderly person is well supported, and also

obstacles that may lead to falls are reduced. In healthcare facilities, the medical team can provide

treatment for diabetes and other conditions which may be increasing the risk of falls among the

elderly (Maan et al., 2021). Considering that the patient, in this case, lives with his wife who is

also dependent, they have also had a social problem that may also impact their psychology.

Diabetes Management

In the clinical management of T2DM, there are both pharmacological and non-

pharmacological. In this case, the patient is on metformin and gliclazide as the pharmacological

measures of managing his situation. Metformin lowers the body glucose levels by improving the

tissue sensitivity to insulin. In most cases, metformin is prescribed when some of the non-

pharmacological measures commonly applied such as exercise and diet fail to control the glucose

level (McClinchy, 2018). The drug is the first-line medication for people with diabetes and

especially those who are overweight. At some point, metformin may stop working, and thus the

patient may receive a new prescription from the doctor that would help in reducing the sugar

levels in the blood. For instance, in the case study, the patient glucose level failed to get

regulated despite him taking the medication provided. However, skipping doses at times
 Case Study Type 2 Diabetes 5

increases the risk of poor blood glucose control. Considering the case of Jack, despite being

within the old age bracket, he also had the responsibility of caring for his wife, and therefore at

times, he likely forgot to take his medication on time hence the failed control of the blood sugar

levels.

Metformin and gliclazide perform the same function of reducing blood glucose, however,

they two work differently. For instance, Metformin reduces the amount of glucose produced in

the liver and also improves the muscle absorption of the glucose in the blood hence ensuring the

normal levels are maintained. When metformin is not found to work effectively under the current

prescription the NHS (2019) guideline recommends that the dosage can be increased until when

there is complete control of the blood glucose level. Gliclazide increases the amount of insulin

produced by the pancreas. However, according to NHS (2019), the gliclazide may decrease its

effectiveness with time hence leading to poor glucose control. A study was done by Gao et al.,

(2020) Showed that certain factors may impact the effectiveness of gliclazide effectiveness in the

body, and including taking painkillers like ibuprofen, antibiotics such as fluconazole. Therefore,

the patient should ensure they provide the doctor with the list of medication they are using before

they get a prescription to ensure its effectiveness. In cases, where the patient is using the

contraindicated medication, the doctor can give an alternative prescription that would help

manage T2DM. In the case where even with the adjusted doses, the glucose levels fail to be

controlled, the doctor may consider prescribing insulin. For instance, the B-cells responsible for

the production of insulin may be damaged to a point where they cannot produce more, and

therefore even with metformin and gliclazide, the blood glucose keeps shooting high (Gao et al.,

2020). Therefore, when the dose of metformin and gliclazide are adjusted, and all other factors

which may impact their effectiveness are addressed and still fail to work, insulin injection may
 Case Study Type 2 Diabetes 6

be recommended. However, in the case study, the patient lives with his wife who depends on

him, and also due to his old age, it may be difficult for him to have the insulin injections and thus

may require assistance.

In managing this patient, there is the need for a multi-disciplinary approach involving the

doctors, social workers and nurses. The care planning is required to be done by different

professionals to ensure that the patient, biological, social and psychological needs are addressed

(Raveendran, Chacko and Pappachan, 2018). For instance, the social and psychological needs

may prevent the patient from taking medication as required hence it may not be effective in

controlling the situation. In this case, the couple staying alone at old age may require the

intervention of social workers to ensure that they get a caregiver. For instance, with the

prescription of daily insulin injection for Jack, it may not be possible for him to visit the hospital

daily for the injection given that he also suffers from arthritis hence making his movement

limited. Social workers can help in getting the family a caregiver who would maintain constant

communication with them to ensure that all is going well and that their medical needs are taken

care of, and also the burden of depending on each other for physical support is reduced.

According to the NICE (2015) guidelines, older adults with diabetes need frequent

review until the HbA1c is stable with the current medication. Also, to ensure effectiveness, the

patients need to be involved in making decisions especially setting the treatment targets that they

would wish to achieve. The patients are provided with lifestyle advice which would also help in

boosting their health and other non-pharmacological measures that can help in managing T2DM.

one of the non-pharmacological measures that can be applied to control T2DM is a dietary

intervention that involves avoiding food that has a high glucose level (Dunning, 2017). However,

when taking insulin, the patient needs to ensure that they have a constant eating schedule to
 Case Study Type 2 Diabetes 7

reduce the chances of hypoglycemia. Insulin works by reducing the blood glucose, however,

when the patient does not eat regularly, they may have lower glucose level than normal which is

life-threatening and require immediate intervention. NICE (2015) advises older adults who

depend on others to aim for an HbA1c of 53mmols/mol as the lower limit hence preventing the

chances of hypoglycemia and hyperglycemia. Therefore, older adults with T2DM need

caregivers to assist them in ensuring that their blood sugar level is checked regularly to maintain

within the normal limits. Jack in this case where his medication is likely to be changed to start

using insulin injection, needs assistance with the injections and also ensuring consistent food

supply to keep his HbA1c within the normal ranges. A study conducted by Forbes et al (2018)

showed that older adults with HbA1c levels below 58mmols/mol had an increased risk of death.

Therefore, this means the lower the blood sugar, the higher the chances of hypoglycemia leading

to death. Keeping the HbA1c levels within the normal ranges by ensuring a constant eating

routine and also diet control would ensure that the patient can manage the situation well. NICE

(2015) encourages older adults with diabetes to consider taking a low-fat diet and consider

lifestyle changes that would improve their overall health. In the case of Jack, he requires a proper

diet plan and together with the family social workers can facilitate them with a caregiver who

would ensure that they take their medication and meals on time to avoid instances of

hypoglycemia which is potentially dangerous to their health.

Care Strategies

Older adults who are diagnosed with T2DM need early intervention and care to prevent

complications of the condition which include neuropathy and kidney disorder. Hyperglycemia

damages the kidney blood vessels which may lead to its failure increasing the health

complication in the individual. Older adults with T2DM may require the approach of a multi-
 Case Study Type 2 Diabetes 8

disciplinary team especially when the patient is also experiencing social and psychological

challenges (Saint-Pierre, Herskovic and Sepúlveda, 2018). In this case, the patient lives with his

wife who depends on him as she also suffers from dementia. In this case, the couple needs

assistance from different professionals to ensure that Jack's condition is effectively managed.

When one is unable to perform their duties at home as expected, they are likely to suffer from

psychological stress which may impact the treatment process.

In this case, the multi-disciplinary team to manage the case of jack would involve

different professionals who include social workers, doctors, psychologists and also the family

(Kastner et al., 2018). Social workers play an essential role in ensuring that the social needs of a

patient are met. For instance, in the case of Jack, he needs assistance at home as he only stays

with the dependent wife. Also, due to old age and several health issues that Jack has, he is now

incapacitated and may not be able to meet both his needs and those of his wife. For instance, due

to the failure of metformin and gliclazide, Jack is likely to be put on insulin injection which he

may not be able to do for himself due to old age. In this case, Jack needs a home caregiver who

would ensure that he adheres to his diet and also help with taking medication within the

recommended hours. Social workers can play a role in linking Jack with the suitable caregiver by

involving his family which includes his children living abroad. Involving the family will ensure

that they approve of the decision of having a family caregiver to provide support for Jack and his

wife in managing their current health condition. Social workers facilitate the patient’s recovery

journey by offering different forms of support which include resources and also psychological

support necessary for the health process (Kastner et al., 2018). The social worker will get

involved in monitoring the progress of the patient until when his condition will have stabilized

(Lee and Halter, 2017). For instance, if the glucose levels remain stable for a week, the social
 Case Study Type 2 Diabetes 9

worker can minimize the visits as the patient will be responding well to the current treatment.

Psychologists would ensure that the patient has proper mental health which would ensure that

they properly take their medication and also adhere to the doctor’s instruction for quick recovery.

Diabetes education programs are essential to help in self-management and also ensure

proper adherence to treatment. People need a proper understanding of lifestyle choices especially

if they have diabetes which would also ensure an increase in their lifespan (Sherifali et al., 2018).

Educating people with diabetes on the importance of dietary changes and treatment adherence

would help in reducing the cases of complications resulting from the condition. For instance,

most complication resulting from T2DM is due to a lack of knowledge on how to manage the

situation on the side of the patient (Litchman, Rothwell and Edelman, 2018). For example, the

patients can be educated on the contraindicated medication while on metformin and other

diabetic medication which would ensure effectiveness in the treatment. Jack would have been a

beneficiary of the education program and would not need much assistance from the caregiver if

he had been educated on self-care for T2DM including the administration of insulin since now he

has no one to depend on and thus requiring the intervention of a social worker. However, in this

case, educating Jack on how to ensure that he takes the correct diet and adheres to medication

will ensure that the condition is effectively managed.

A study done by Owens-Gary et al. (2019), older adult patients with diabetes needs to be

screened for a mental illness especially depression as they are at an increased risk. The

management of T2DM for older adults especially those who do not have family close to support

them may be challenging which leads to stress hence impacting treatment adherence (Litchman,

Rothwell and Edelman, 2018). T2DM patients need constant evaluation by qualified medical

personnel and therefore need to visit the hospital frequently and this may also add up to their
 Case Study Type 2 Diabetes 10

stress leading to depression. for instance, in the case of Jack, he already has a lot to do as he is

the only person taking care of his wife and now that he is feeling unwell, he is likely to sink into

depression and thus the need to have a psychologist evaluate and provide intervention for him.

Ensuring proper mental health for patients with diabetes would ensure effectiveness in the

treatment process as they are more likely to adhere to the treatment (Owens-Gary et al., 2019).

Providing mental support for patients with diabetes especially at old age is found to increase

their life span and also improve their quality of life. Therefore, the doctor managing the case of

Jack should insist on psychological assistance which would improve his response to treatment

bringing his T2DM under control.

Conclusion

Diabetes care in older adults is a complex process as one has to consider the multiple co-

morbidities that they often have. The prescription of the required medication may be hard

especially if they are taking contraindicated medicine for other conditions. For instance,

metformin is contraindicated for pain relief medicines such as ibuprofen. Therefore, patients

taking different medicines for various conditions may find it difficult getting the right

prescription for diabetes and most are often left with only insulin as their only choice. The use of

insulin in older adults is a challenge as it requires self-administration which may be difficult for

them. older adults staying alone may need a caregiver which increases their cost of treatment. At

times the care planning for older adults with T2DM requires a multi-disciplinary approach

whereby the team involved should ensure that the patient receives the best possible care and they

also collaborate with their family to help in improving the quality of life for the patient. As part

of diabetes care, older adults need to be screened for depression as they are at risk due to the

reduced quality of life. On reflection, I have realized that the T2DM patients I care for with co-
 Case Study Type 2 Diabetes 11

morbidities need to be involved in the decision making process which will ensure that they

understand well what they need to do to achieve their treatment goals and improve their quality

of life.
 Case Study Type 2 Diabetes 12

References

Bulut, E.A., Soysal, P., Aydin, A.E., Dokuzlar, O., Kocyigit, S.E. and Isik, A.T., 2017. Vitamin

B12 deficiency might be related to sarcopenia in older adults. Experimental

gerontology, 95, pp.136-140.

Dunning, T. (2017) Care of older people with diabetes. Nursing Standard. Vol 32, (3). pp 50-61.

Forbes, A., Murrells, T., Mulnier, H. and Sinclair, A.J., 2018. Mean HbA1c, HbA1c variability,

and mortality in people with diabetes aged 70 years and older: a retrospective cohort

study. The lancet Diabetes & endocrinology, 6(6), pp.476-486.

Galicia-Garcia, U., Benito-Vicente, A., Jebari, S., Larrea-Sebal, A., Siddiqi, H., Uribe, K.B.,

Ostolaza, H. and Martín, C., 2020. Pathophysiology of type 2 diabetes

mellitus. International journal of molecular sciences, 21(17), p.6275.

Gao, S., Chen, Y., Hu, R., Lu, W., Yu, L., Chen, J., Liu, S., Guo, Y., Shen, Q., Wang, B. and

Fang, W., 2020. Visualized analysis and evaluation of simultaneous controlled release of

metformin hydrochloride and gliclazide from sandwiched osmotic pump capsule. Drug

Development and Industrial Pharmacy, 46(11), pp.1776-1786.

International Diabetes Federation (2017) IDF Clinical Practice Recommendations for managing

Type 2 Diabetes in Primary Care. International Diabetes Federation.

www.idf.org/managing-type2-diabetes

Kastner, M., Cardoso, R., Lai, Y., Treister, V., Hamid, J.S., Hayden, L., Wong, G., Ivers, N.M.,

Liu, B., Marr, S. and Holroyd-Leduc, J., 2018. Effectiveness of interventions for

managing multiple high-burden chronic diseases in older adults: a systematic review and

meta-analysis. Cmaj, 190(34), pp.E1004-E1012.
 Case Study Type 2 Diabetes 13

Lee, P.G. and Halter, J.B., 2017. The pathophysiology of hyperglycemia in older adults: clinical

considerations. Diabetes Care, 40(4), pp.444-452.

Lee, P.G. and Halter, J.B., 2017. The pathophysiology of hyperglycemia in older adults: clinical

considerations. Diabetes Care, 40(4), pp.444-452.

Litchman, M.L., Rothwell, E. and Edelman, L.S., 2018. The diabetes online community: older

adults supporting self-care through peer health. Patient education and counseling, 101(3),

pp.518-523.

Maan, H.B., Meo, S.A., Rouq, F.A. and Meo, I.M.U., 2021. Impact of Glycated Hemoglobin

(HbA1c) on cognitive functions in Type 2 diabetic patients. European Review for

Medical and Pharmacological Sciences, 25(19), pp.5978-5985.

McClinchy, J (2018) Dietary management of older people with diabetes. British Journal of

Community Nursing. Vol 23, (5), pp 248-251.

NHS., 2019. Metformin. Retrieved from: https://www.nhs.uk/medicines/metformin/

NHS., 2019., gliclazide. Retrieved from: https://www.nhs.uk/medicines/gliclazide/

NICE (2015) Type 2 diabetes in adults: management. National Institute for Health and Care

Excellence

Owens-Gary, M.D., Zhang, X., Jawanda, S., Bullard, K.M., Allweiss, P. and Smith, B.D., 2019.

The importance of addressing depression and diabetes distress in adults with type 2

diabetes. Journal of general internal medicine, 34(2), pp.320-324.

Raveendran, A.V., Chacko, E.C. and Pappachan, J.M., 2018. Non-pharmacological treatment

options in the management of diabetes mellitus. European endocrinology, 14(2), p.31.

Saint-Pierre, C., Herskovic, V. and Sepúlveda, M., 2018. Multidisciplinary collaboration in

primary care: a systematic review. Family practice, 35(2), pp.132-141.

 Case Study Type 2 Diabetes 14

Sherifali, D., Berard, L.D., Gucciardi, E., MacDonald, B. and MacNeill, G., 2018. Self-

management education and support. Canadian Journal of diabetes, 42, pp.S36-S41.

Su, J.B., Zhao, L.H., Zhang, X.L., Cai, H.L., Huang, H.Y., Xu, F., Chen, T. and Wang, X.Q.,

2018. HbA1c variability and diabetic peripheral neuropathy in type 2 diabetic

patients. Cardiovascular diabetology, 17(1), pp.1-9.