NR 601 Final Exam Review: Weeks 5-8 Content

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Week 5: Glucose Metabolism Disorders

Types of Diabetes (Prediabetes, Type 1, and Type 2)

• Islet Cell-Specific Antibodies: Found in 70-80% of individuals with prediabetes and newly diagnosed Type 1 Diabetes (DM1). Hyperglycemia typically develops after 80-90% of beta cells are destroyed.
• Type 1 Diabetes: An autoimmune attack on the pancreas’s beta cells prevents insulin production and secretion, leading to insulin deficiency.
• Type 2 Diabetes: The pancreas continues to secrete insulin, but cells throughout the body fail to respond adequately (insulin resistance), resulting in relative insulin deficiency.
• Diagnostic Criteria: Based on ketonuria, age of onset, and BMI. Antibody testing and c-peptide levels help determine the type:
  • Type 1: Antibodies present in 70-80%, extremely low c-peptide levels.
  • Type 2: Typically occurs in individuals ≥ 40 years old with a BMI > 27 and minimal/no ketonuria.
  • Diagnosis is confirmed with either two fasting blood glucose (FBG) levels ≥ 126 mg/dL or a random blood glucose (BG) level ≥ 200 mg/dL with symptoms.
  • Symptomatic patients with one positive test are diagnosed with DM2; asymptomatic patients require two positive tests.
  • HbA1c ≥ 6.5% indicates DM2.
• Screening Recommendations: For anyone overweight with additional risk factors; begins at 45 years old and repeated every 3 years.
• Initial Treatment for Type 2:
  • Lifestyle modifications (weight loss, exercise) are first-line therapy.
  • If non-pharmacologic treatment fails after 3-6 months or if FBG is 200-300 mg/dL, add Metformin. Dual pharmacotherapy is not recommended unless HbA1c ≥ 9%.
  • Metformin (Glucophage): Decreases hepatic glucose production, intestinal glucose absorption, and increases insulin sensitivity. Initial dosing is 500 mg daily, then BID.
  • Sulfonylureas: Increase pancreatic insulin secretion, lowering HbA1c by 1.25%.
  • Meglitinides: Increase insulin release from the pancreas, reducing HbA1c by about 1%.
  • Thiazolidinediones (TZDs): Increase insulin sensitivity, reduce A1c by 1-1.5%, but contraindicated in patients with HF, bladder cancer, osteoporosis, or liver disease.
  • Dipeptidyl Peptidase-4 (DPP-4) Inhibitors: Increase bioavailability of GLP1, used once daily.
  • Alpha-Glucosidase Inhibitors: Delay glucose absorption, lower serum triglycerides, and reduce A1c by 0.8%.
  • Sodium-Glucose Cotransporter 2 (SGLT2) Inhibitors: Block glucose reabsorption in the renal tubule, increase urinary glucose excretion, reduce A1c by 0.5-1%.
• Initial Treatment for Type 1 and DKA: Always insulin, with differences based on onset and duration of action.
• Treatment Goals for Older Adults: Consider health beliefs, life expectancy, functional status, economic situation, and support services.
• Response to Treatment: Based on home BG monitoring and HbA1c, with follow-up visits including BP, BMI, foot exams, annual eye exams, and various lab tests.
• Weight Loss Recommendations: In obese adults, a 5-10% total body weight loss can improve glycemic control and delay DM2.
• Risk Factors for Developing DM2: Age ≥ 45, family history, race, hyperlipidemia, history of GDM, PCOS, obesity, smoking, HTN, and more.
• Risk Factors in the Elderly: Increased abdominal fat, decreased physical activity, sarcopenia, mitochondrial dysfunction, and hormonal changes.

Complications of DM

• Macrovascular: CAD, stroke, PVD.
• HbA1c > 13%, Fasting BG > 300 mg/dL: Can lead to altered behavior, seizures, coma.
• Atherosclerosis, HLD, Retinopathy, Depression, DKA, Blindness, HTN, Sexual Problems: Common complications.
• End-Stage Renal Disease, Lower Extremity Amputations, Slow Wound Healing: Severe complications.

Treatments for Complications

• ACE Inhibitors: Postpone microalbuminuria and nephropathy progression.
• Daily Aspirin: Reduces CVD risks.
• Obesity Management: Through diet, exercise, and possibly surgery.
• Lifestyle Management: Includes nutritional education, sleep hygiene, stress reduction, and smoking cessation.
• Hypoglycemia Management: Treat with juice, soda, or milk if BG < 70; BG < 54 is considered severe.

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Week 6: Urology and Aging

UTI Risk Factors and Differences by Gender

• Pathophysiology and Common Bacterial Causes
• UTI Diagnostic Criteria and Treatment Guidelines
• Incontinence: Causes and management.
• Hematuria and Proteinuria: Causes and diagnostic approach.

Sexuality and Aging

• STIs: Increased risk and management in aging populations.
• Age-Related Changes: Affecting sexual health.

Genitourinary Syndrome of Menopause (GSM)

• Signs and Symptoms, Diagnosis, and Treatment

Menopause

• Menstrual Changes Physiology and Symptom Management

Erectile Dysfunction

• Diagnosis, Treatment, Half-Life of Medications, Medication Interactions, and Comorbid Diagnoses

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Week 7: Elder Abuse, Alzheimer’s, Delirium, and Dementia

Elder Abuse

• Types of Abuse and Provider Responsibilities

Alzheimer’s Disease

• Distinguishing Features, Staging Guidelines, and Treatment

Delirium

• Distinguishing Features, Common Causes, and Prevention Strategies

Dementia

• Distinguishing Features, Common Types, Duration of Symptoms, and Treatment

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Week 8: Ethical Issues and End of Life Care

Ethical Issues and Barriers to End of Life Care

• Differences Between Palliative Care and Hospice

Advanced Directives/Advanced Care Planning (ACP)

• Barriers to ACP, Durable Power of Attorney for Healthcare, and POLST Criteria

Palliative Care

• Eligibility Criteria, Services, Length of Eligibility, and Symptom Management

Hospice Care

• Eligibility Criteria, Services, Length of Eligibility, and Symptom Management

Pain Management in Palliative and Hospice Care

• Medication Indications, Onset of Action, and Side Effects

Grief

• Complicated vs. Uncomplicated Grief: Symptoms and Duration