LITERATURE REVIEW – IMPACT OF DIABETES ON PHYSICAL FUNCTION IN OLDER PEOPLE
Diabetes and Physical Disability
(2005) states that diabetes is a notorious epidemic which affects mostly the elderly people. Disability affects about 20 to 50% of the diabetic population whereby 2 to 3 persons with diabetes are more likely to be disabled than non-diabetics. Disability is defined in relation to its impact on the individual either functionally, medically, anatomically or emotionally. As such, diabetes is associated with disability is several processes which may lead to temporary impairment that is associated with physical and social limitations. In physical disability in diabetics in particular, there are multiple factors which implicate in the pathogenesis of such including cardiovascular disease, obesity, stroke, visual impairment, peripheral nerve dysfunction, peripheral arterial disease, falls and depression. With this said, structured exercise programs and weight lost programs could improve the physical ability of older people with diabetes.
According to (2005), physical disability is increasingly being recognized as both challenge and consequence for older adults with diabetes. The effects of diabetes on disability greatly differ between middle-aged and older adults. The characteristics of associating diabetes with physical disability as well as the extent to which the effects of diabetes to physical functioning covers gaps which implicate appropriate diabetes management. Based on the data from two parallel national panel studies, the researchers was able to conclude that diabetes was strongly associated with subsequent physical disability in middle aged and older adults.(2005) made use of composite variable that combines activities of daily living, mobility, and strength tasks. One of the significant predictor of disability in both groups lies in the control of socioeconomic characteristics and other diabetic-related conditions. As such, there is the necessity to prevent and mitigate disability as an important diabetes-related health outcome in middle aged and older adults.
According to (2006), diabetes increases the risk for mobility limitation among older adults with diabetes. The author advised that the monitoring of prevalence of diabetes is crucial especially because inherent to the medical disorder are risks factors centering the burden of mobility limitation. (2006) said that the prevalence of mobility limitation among adults with diagnosed diabetes was greater than those without diagnosed diabetes and that the odds of mobility limitation were greaterfor adults with diagnosed diabetes. Commonly, mobility restraints were related to walking a quarter of mile and walking up to 10 steps. Older adults with diabetes (33%) were reported having difficultieswalking a quarter of a mile and difficulties walking up 10 steps.
(2005) aver that the already high and increasing prevalence of diabetes amongolder adults will make ageing-related outcomes like physicaldisability an increasingly important complication of diabetes. For them, disability is a key indicator of both overall morbidity and success of public health initiatives especially for diabetic older adults. Diabetes is always associated with increased risk of disabilities in mobility and in instrumental and basic activities of living. Higher disability among older patients with diabetes is also associated with comorbidities such as multifactor withneuropathy, peripheral arterial disease, coronary heart disease,depression, obesity, visual impairment, and physical inactivity as these factors impose greater risk and effects of disability. The existence of interventions varies from exercise programs, identification and treatment of depression, long term prevention of disability by means of glycerin and risk factors for cardiovascular disease. (2005) proposed that the prevention of disability will depend on the combination of secondary and tertiary prevention along with preventing diabetes at the onset.
(2002) assert that diabetes is now a global epidemic; however, physical ability and cognitive decline are two underappreciated diabetes-related problems. In industrialized countries, most especially, diabetes is more among the elderly people due to the ageing of the overall populationas well as a greater absolute increase in the prevalence of diabetesamong elderly people than among young people. As cited in the article, diabetes is also associated with greater risks of disabilities related to mobility and daily tasks among elderly people. As such, the association of diabetes with physicaldisability is explained in part by and because of classic complications of diabetes. The authors ended their discussion with stating that as the number of older people with diabetes and other chronic diseases increases, outcomes such as cognitive and physicaldisability will become greater concerns because of their implicationsfor quality of life, loss of independence, and demands on caregivers.
Diabetes and Comorbidities
The role of diabetic complications and comorbidity in the association between diabetes and disability in the elderly is a common subject in diabetic research. (2004) made use of data from a nationally representative sample 5632 older Italians, aged 65 years and older. A physician conducted clinical diagnoses of diabetes and other major chronic conditions and disability was assessed by self-reported information on activities of daily living and physical performance tests. Disability on the basis of activities of daily living was associated with diabetes in women, but not in men and in contrast, the association between severe and/or total disability on the basis of physical performance tests and diabetes was strong in both sexes.
As (2006) put it, important is to assess which of the broad range of determinants of health are most strongly associated with health-related qualityof life (HRQL) among people with diabetes. Studying the Canadian respondents, the researchers found out that comorbidities had the largest impact on HRQL including stroke and depression. Likewise, stress, physical activity, and sense of belongingalso were important determinants as well as social assistance and food insecurity.(2006) concluded their study with stating that ‘social and environmental factors are important,but comorbidities have the largest impact on HRQL among peoplewith diabetes’.
(2005) investigated the associations between diabetes and disability in three domains and to determine whether the associations are mediated by diabetes-related complications. Basic activities of daily living (ADLs), instrumental ADLs, and mobility are the three domains examined. Through studying of 2, 003 of older adults with diabetes, (2005) found out that older adults with diabetes are more likely to report difficulty in 12 of 15 ADLs than older adults without diabetes. Further, diabetic patients with diabetes are about twice as likely to report disability in higher functioning tasks only, as well as mobility and higher functioning tasks, and 3.5 times as likely to report disability in self-care tasks with or without any other mobility or higher functioning tasks as those without diabetes. (2005) winded up their study with emphasizing that diabetes is strongly related to a wide range of disabilities in older Hong Kong adults and the underlying mechanisms might be different for different categories of disability.
Major depression, additionally, is a comorbidity of diabetes, leading to functional disability. (2004) tried to determine the prevalenceand odds of functional disability in individuals with diabetesand comorbid major depression compared with individuals witheither diabetes or major depression alone. He found out that the odds of functional disability was higher for those with diabetes based on the data collected through 30, 022 adults with diabetes. The study concluded that diabetes and comorbid depressions have higher associations, contributing to the likelihood of functional disability.
Since cognitive decline is also apparent for older people with diabetes, another comorbidity by which functional disability is being associated upon is the common mental disorders. According to (2007), there is the necessity to determine the associations between diabetes and common mental disorders as well as the associations between comorbid common mental disorders with the quality of life and diabetes and self-care indicators. The conducted study proved that people with diabetes were more likely to suffer from commonmental disorders and among people with diabetes, common mental disorders were significantlyassociated with impaired health-related quality of life, moredays off work, nonadherence, and difficulties with diabetesself-care.
Visual acuity is another comorbidity that is not usually considered. and his collaborators (2000) explored such issue, aiming to screen for impaired distancevisual acuity in older adults with and withoutdiabetes mellitus to determine whether diabetes increase the likelihood ofvisual impairment and to identify associatedfactors. With the comparison of the groups, the authors found out that diabetes was associated with an increased risk of visual impairment hence the significant association with impaired visual acuity and five domains of the SF-36 as physical and social functioning, mental health, vitality, and healthperceptions. As such, diabetes mellitus isassociated with significantly increased risk of visual loss and thisimpairment is associated with detriments in health-related quality of life. Particularly, SF-36 is the simplified short-form 36 questionnaire.(1993) tested the validity of the instrument and found that there is a high degree of internal consistency. As such, SF-36 is suitable for use with an elderly populationwhen used in an interview setting.
(2007) explored the nature of functional impairment in older people with diabetes. In a population-based case-control study conducted, the authors discovered that subjects with diabetes had more comorbidities than control subjects and were more likely to have severe functional impairment. The health status of the older adults in relation to physical function emphasize that diabetes remained significantly associated withmobility limitation. (2007) concluded that older people with diabetes have considerable functional impairment associated with reduced health status, recommending that older adults may benefit from comprehensive geriatric assessment and tailored diabetes management.
(2005) reiterated that diabetes mellitus is an important public health concern with impact that is increased by the high prevalence of co-existing chronic medical conditions. The authors evaluated how diabetes and other chronic medical conditions could affect the health-related quality of life. The chronic medical conditions considered are hypertension, heart disease and muscoskeletal illnesses. Generally, the co-existence of diabetes and chronic conditions reduced the health-related quality of life of elderly people with diabetes.
(2002) described the incidence of falls, risk factorsfor falls, and the frequency of fall-related fractures in acohort of individuals with diabetes and a prior foot ulcer in their study. With a total of 400 individuals with diabetes, the researchers were able to determine the association of diabetes with fall-related morbidity, emphasizing that he presence of one or more comorbid conditions,and insensate feet increased the risk including two or more falls ofany type were associated with a higher fracture risk. (2002) concluded that falls are very common in individuals withdiabetes and prior foot ulcers, and were significantly higher in women than in men.
Diabetes and Older Men vs. Women
Another study which deals with older women with diabetes is that of (2002). (2002) examined the relationship between diabetesand the incidence of functional disability and to determinethe predictors of functional disability among older women withdiabetes. Women aged ≥ 65 years were the subject of the analysis and were assessed by using questionnaire and physical examination over 12 years. The authors defined incident disability as onsetof inability to do one or more major functional tasks. Findings proved that the annual incidence of any functional disability which is associated with comorbidities was 9.8% among women with diabetes and 4.8% among women without diabetes. As such, diabetes remained associated with a 42% increased risk of anyincident disability and a 53–98% increased risk of disabilityfor specific tasks. (2002) concluded that diabetes is associated with an increased incidenceof functional disability, which is likely to further erode healthstatus and quality of life.
(2004) attempted to identify the patterns of disability related to diabetes in older women and distinguish the extent to which disability is mediated by selected diabetes complications. The results of the study include: women with diabeteswere significantly more likely to report difficulty in 14 of15 daily tasks. Some of these are walking 2–3 blocks, lifting10 pounds, using the telephone, and bathing. Further, women with diabetes were about twiceas likely to report difficulty in any one of four functioning groups consisting of mobility, upper extremity, higher functioning tasks,or self-care. These women are also and over three times as likely to report difficulty in a groupcombining higher functioning and self-care tasks. As such, diabetes is clearly associated with a wide range of disabilities in older women.
(2002) inspected the role of diabetes-related impairments and comorbidities in the association between diabetes and physical disability by examining the association between diabetes and lower extremity function of older women with diabetes. The cross-sectional analysis of 1, 002 women resulted in particular findings that women with diabetes had a greater prevalence of mobility disability, activities of daily living disability and severe walking limitation. The main contributing factors are peripheral artery disease, peripheral nerve dysfunction, and depression. Even so, none of these conditions alone fully explained the association between diabetes and disability. and his colleagues (2002) concluded that even among physically impaired older women, diabetes is associated with a major burden of disability. The researchers also contend that several impairments and comorbidities explain the diabetes-disability relationship, suggesting that the mechanism for such an association is multifactor.
(2000) estimated the prevalence of physical disability associated with diabetes among elderly adults in the US. The findings of the survey of 6,588 community-dwelling men and women > or =60 years of age suggest that 32% of women and 15% of men reported an inability to walkone-fourth of a mile, climb stairs, or do housework. (2000) claim that diabetes was associated with increased odds of not being able to do each task among both men andwomen. For women with diabetes, diabetes was also associated with slower walking speed,inferior lower-extremity function, decreased balance, and an increased riskof falling. The authors concluded that diabetes is associated with a major burden of physical disability in olderU.S. adults, and these disabilities are likely to substantially impairtheir quality of life.
Diabetes and Lower Extremity Disability
(2003) assert that older people with diabetes are more likely to have a higher prevalence of multiple risk factors for physical disability, resulting from the diabetes complications. Although the three-year longitudinal cohort study focuses on the case of women, the authors found out that impaired lower extremity function is a long-term diabetic complication in older patients. (2003) suggested that a comprehensive assessment of older diabetic patients must include a standardized evaluation of the performance of lower extremity. (1995) recuperate that functional assessment is an important part of the evaluation of elderly persons. The researchers conducted a study to determine if objective measures of physical function could predict subsequent disability in older persons with emphasis given on functionality of lower extremity. The study pronounced that the increase in the frequency of disability in the activities of daily living and mobility-related disability is evident.
Lower body disability is said to be common among diabetic older people. A specific study such matter revealed that 48.7% of the of the 1, 835 of Mexican American older adults with ≥65 years old at baseline developed limitations in one or moremeasures of lower body function over a seven-year period of study. Aiming to examine the interplay between the two variables as diabetes and lower body disability, the study also found out that olderage and having one or more diabetic complications were significantlyassociated with increased risk of limitations in any lower bodyADL and mobility task. The authors suggested that awareness of disability as a potentially modifiable complicationand use of interventions to reduce disability should becomehealth priorities ( 2005).
(2007) supposed that diabetes in older adults is associated with a 2- to 3-times increased risk for falls and physical disability, and that muscle strength is reduced especially in the lower extremities. During a three-year period, the authors examined adults with diabetes aged 70 to 79 and then examined the rate loss of f upper and lower extremity skeletal muscle mass, strength, and quality. (2007) found out that those with diabetes had greater body weight, body mass index, total fat mass, and total lean mass. Nonetheless, individuals with or without diabetes lost significant amounts of initial muscle strength. Findings also point out that older adults with type 2 diabetes lost their knee extensor strength more rapidly than those without diabetes and also lost greater amounts of lean leg muscle mass. However, changes in hand grip strength and arm muscle quality were not different between those with and without diabetes, although hand muscle mass declined more in patients with type 2 diabetes.
Particularly, gait characteristics differ among individualswith diabetes compared to those without diabetes. Nonetheless, there is limited explanation about the association of gait characteristic and diabetes. (2008) studied the association betweendiabetes and gait characteristics in older adults and explored potential explanatory factors. The researchers have learned that diabetes was related to gait speed and is partially explained by factors as health status, visual impairment, lower-extremity strength,physical activity and body mass index. Evidently, diabetes was associated with gait alterations of the people suffering from the disorder.
Diabetes and Muscle Strength and Quality
(2006) also studied how muscle strength and quality in older adults with diabetes contribute to the chances of physical disability. The authors maintain that adequate skeletal muscle strength is essential for physical functioning and low muscle strength is a predictor of physical limitations, and the risk of physical disability is three times higher to older people with diabetes. According to their population study of 485 adults with diabetes, they found out that older adults with diabetes had greater arm and leg muscle mass than those without diabetes because they were bigger in body size. Despite such fact, muscle strength was lower in men with diabetes and not higher in women with diabetes than corresponding counterparts. Muscle strength per unit regional muscle mass or simply muscle quality was significantly lower in men and women with diabetes than those without diabetes in both upper and lower extremities. In sum, there is a clear association with diabetes, muscle strength and quality and physical limitations in older adults with diabetes.
(2005) also said that older adults with diabetes are more likely to have poor muscle quality and accelerated loss of strength over a three-year period. According to epidemiologist, “these characteristics may contribute to the development of physical disability in older adults with diabetes.” A known fact, moreover, is that older adults with diabetes face a two- to threefold higher risk of physical disability. However, the increased risk with respect to changes in muscle characteristics is an area not yet explored. Park reported that older adults with diabetes had greater leg muscle mass but knee extensor strength was lower in diabetic men. Absolute strength at baseline did not differ by diabetes status, but muscle quality was significantly lower in women with diabetes.
Diabetes and the Role of Clinician and Treatment
(2006) stress that the increasing prevalence of diabetes is a major health concern. Reducing complications of diabetes has been a focus on treatment. However, the authors also highlight that less recognized complications of physical disability, cognitive impairment and depression which impact the quality of life of older adults are equally important in primary care considerations in older patients with diabetes. The researchers discovered that slower muscle contraction which is more common in diabetic older adults is a significant contributor to both balanceand gait impairment. As such, there is an interconnection between muscle power, contraction velocity and physical disability among diabetic patients. (2006) also claim that compliance to exercise activities and/or physical treatments was related to improved mobility.
In their study, (2007) inspected the dynamics of disease prevention andmanagement while also determining the prevalence ofphysical activity among adults with and at risk for diabetes. The findings of the study are summarized as: A total of 39% of adults with diabetes were physicallyactive versus 58% of adults without diabetes. The proportionof active adults without diabetes declined as the number ofrisk factors increased until dropping to similar rates as peoplewith diabetes. After adjustment for sociodemographic and clinicalfactors, the strongest correlates of being physically activewere income level, limitations in physical function, depression,and severe obesity. Several traditional predictorsof activity such as sex, education level, and having received pastadvice from a health professional to exercise more were not evident among respondents with diabetes. With these results, (2007) suggested that there is the necessity to target interventions to increase the physical activity of patients with diabetes or at highest risk of developing Type 2 diabetes by reason of lack of engagement in regular physical activities.
According to (2006), it is necessary for every clinician who manage older people with diabetes the special skills for the purpose of providing high quality care. The approach must be influenced by multitude of factors including the higherfrequency of medical comorbidities, frailty, and socioeconomicissues. The author also maintains that comprehensive geriatric assessment is a potentially important tool in ensuring that patients with diabetes receivea multi-professional assessment of their functional status andunmet needs. The target thereby is effective goal setting of providing additional means of conforming therapeutic approaches.
(2006) assessed that diabetes self-management education (DSME) for older adults is a complicated endeavour. This is because of the high prevalence of medical comorbidities and declining functional status. In order for the diabetes health community to adequately meet the educational needs of older adults with diabetes, DSME should be individualized and also involve multiple disciplines, care partners for patients who cannot assume full responsibility of own self-care. There is also the necessity to weigh the potential effects of diabetes treatments on quality of life. ended their discussion with suggesting that in providing appropriate carefor these patients is to ensure that an adequate initial assessmentis provided for them. The special needs of this population as well as the cognitive and physical issues must be also taken into account.
Furthermore, achieving self-care goals would not be easy for older adults with diabetes especially when there is the inexistence of physical barriers. Physical barriers could pose challenges in sustaining the quality of life for older diabetic adults. The decision-making process for developing strategies to overcome physical barriers is thereby a must. (2001) stresses that physical barriers may or may not be diabetes-related; there are various diabetes-related complications and manifestations and could arise from long term complications of diabetes, requiring the development of adaptive strategies. The types of physical barriers to functionality include: long term and short term barriers, cognitive and non-cognitive barriers.
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