NR601 FINAL EXAM STUDY GUIDE Week 5 Glucose metabolism disorders

28 August 2024

NR601 Final Exam Study Guide

Week 5: Glucose Metabolism Disorders

Types of Diabetes Mellitus (DM)

  1. Type 1 Diabetes: Characterized by severe insulin deficiency due to the reduction or absence of functioning beta cells in the pancreatic islets of Langerhans. This leads to hyperglycemia resulting from altered metabolism of lipids, carbohydrates, and proteins.
    • Subjective Findings: Symptoms include polyuria, polydipsia, nocturnal enuresis, polyphagia with paradoxical weight loss, visual changes, and fatigue.
    • Objective Findings: Physical signs include dehydration (poor skin turgor, dry mucous membranes), weight loss despite a normal or increased appetite, and reduced muscle mass.
    • DKA: Symptoms include fatigue, cramping, and abnormal breathing.
  2. Type 2 Diabetes: Defined by abnormal insulin secretion, resistance to insulin action in target tissues, and/or an inadequate response at the insulin receptor level.
    • Symptoms: Patients may present with pruritus, fatigue, neuropathic complaints (such as numbness and tingling), or blurred vision.
  3. Prediabetes: A state where fasting glucose levels are consistently elevated above the normal range but less than 100-125 mg/dL. Impaired glucose tolerance (IGT) is defined by hyperglycemia where the 2-hour post-glucose load glycemic level is 140-199 mg/dL.

Diagnostic Criteria for DM

There are four lab-based criteria for confirming diabetes:

  • A1C of 6.5% or higher indicates diabetes.
  • Random plasma glucose level of 200 mg/dL or higher with classic symptoms of hyperglycemia or a hyperglycemic crisis.
  • Fasting plasma glucose level of 126 mg/dL or higher on two separate occasions (fasting is defined as no caloric intake for at least 8 hours).
  • 2-hour post-load plasma glucose level of 200 mg/dL or higher during an OGTT, following the consumption of a glucose load equivalent to 75g of anhydrous glucose dissolved in water (OGTT is also used to screen for diabetes during pregnancy).

In the absence of unequivocal hyperglycemia, results should be confirmed by repeat testing on a new blood sample without delay, preferably using the same type of test.

Initial Treatment

  • Type 1 Diabetes: The first-line treatment is insulin. The goal is to normalize elevated blood glucose levels using intensive insulin regimens. Treatment goals include plasma glucose levels of 80-130 mg/dL before meals, postprandial glucose levels below 180 mg/dL, and an A1C below 7% for adults. Management includes exogenous insulin, frequent self-monitoring of blood glucose (SMBG), medical nutrition therapy, regular exercise, and continuous education on preventing and treating diabetic complications. Insulin therapy in newly diagnosed Type 1 DM should be managed by or in close collaboration with an endocrinologist.
  • Type 2 Diabetes: First-line treatment involves lifestyle management, focusing on risk reduction and glycemic control through nutrition therapy, exercise, and mental health management. Pharmacological therapy is required when lifestyle changes are insufficient. Metformin is recommended unless contraindicated (e.g., renal disease, abnormal creatinine clearance). If glycemic goals are not met after 3 months, add a second agent or insulin therapy.

Medication Side Effects

  • Type 1 Diabetes: Hypoglycemia is common due to excessive exogenous insulin, missed meals, or excessive exercise. Symptoms include diaphoresis, tachycardia, hunger, shakiness, altered mentation, slurred speech, and seizures. Hypoglycemia is considered serious at glucose levels below 54 mg/dL.
  • Type 2 Diabetes: Metformin can cause hypoglycemia, particularly in older adults, and is contraindicated in renal disease. It may also cause GI disturbances and a metallic taste. Long-term use may lead to vitamin B12 deficiency, requiring periodic testing.

Treatment Goals for Older Adults

  • Healthy Older Adults: A1C <7.5%, fasting glucose 90-130 mg/dL, bedtime glucose 90-150 mg/dL, BP <140/90 mmHg. Use statins unless contraindicated.
  • Complex Older Adults: A1C <8.0%, fasting glucose 90-150 mg/dL, bedtime glucose 100-180 mg/dL, BP <140/90 mmHg. Use statins unless contraindicated.
  • Very Complex Older Adults: A1C <8.5%, fasting glucose 100-180 mg/dL, bedtime glucose 110-200 mg/dL, BP <150/90 mmHg. Statins should be considered based on the likelihood of benefit.

Weight Loss Recommendations

Lifestyle modifications, including weight loss and exercise, are crucial in lowering HbA1c. A modest weight loss of 5% can improve glycemic control.

Risk Factors

  • Type 1 Diabetes: Autoimmune factors, genetic predisposition (chromosome 6p), and monogenic forms.
  • Type 2 Diabetes: Family history, obesity, age over 45, hypertension, hyperlipidemia, history of gestational diabetes, and certain ethnicities (African American, Latino, Native American, Asian American, Pacific Islander).

Complications

  • Type 2 Diabetes: The leading cause of acquired blindness in adults aged 20-74. Acute complications include diabetic ketoacidosis, severe hyperglycemia, and hypoglycemia with neurological symptoms. Chronic complications include renal failure, coronary artery disease, stroke, peripheral vascular disease, and slow-healing wounds.

Treatment for Complications

  • Hyperlipidemia: Use statins alongside nutritional therapy.
  • Referrals: Patients should be referred to a dietician, certified diabetes educator, endocrinologist, and should have annual exams of the feet and eyes.

Week 6: Urology and Aging

Urinary Tract Infections (UTIs)

  • Types: UTIs can be acute, chronic, recurrent, complicated, or uncomplicated.
  • Risk Factors: Include indwelling catheters, incontinence, cognitive impairment, diabetes, and poor hygiene. Men have a lower incidence of UTIs due to the protective properties of prostatic fluid.
  • Common Bacteria: E. coli is the most common cause of uncomplicated UTIs, accounting for 80-90% of cases in women.
  • Treatment: Uncomplicated UTIs are treated with nitrofurantoin or trimethoprim-sulfamethoxazole. Treatment duration varies, with longer courses for complicated cases or in older men.

Incontinence

  • Types: Stress, urge, mixed, overflow, and functional incontinence, each with different management strategies.
  • Risk Factors: Include pelvic muscle weakness, diabetes, stroke, and medications.

Sexuality and Aging

  • STIs: Older adults remain sexually active and are at risk for STIs due to changes in sexual behavior and physiology. Education on safe sex practices is essential.

Genitourinary Syndrome of Menopause (GSM)

  • Symptoms: Include vaginal dryness, dysuria, and dyspareunia.
  • Treatment: Over-the-counter moisturizers and lubricants are first-line, with low-dose vaginal estrogen therapy as a next step if necessary.

Menopause

  • Symptom Management: Includes lifestyle modifications, SSRIs, and hormone therapy, with attention to contraindications.

Erectile Dysfunction (ED)

  • Causes: Include physiological, psychological, and vascular factors.
  • Diagnosis and Treatment: Initial lab tests include fasting blood sugar, lipid profile, TSH, and testosterone levels. Treatment includes lifestyle changes, pharmacotherapy (e.g., PDE5 inhibitors), and hormone therapy if indicated.

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

Elder Abuse

  • Types: Physical, sexual, emotional, neglect, exploitation, abandonment, and self-neglect.
  • Provider Responsibilities: Healthcare professionals must report suspected abuse and carefully document all findings.

Alzheimer’s Disease

  • Features: Progressive cognitive decline with memory loss, impaired executive function, and behavioral changes.
  • Treatment: Includes pharmacological (cholinesterase inhibitors) and non-pharmacological interventions (support groups, cognitive therapies).

Delirium

  • Features: Rapid onset of confusion, disorientation, and cognitive changes, often due to an underlying medical condition.
  • Prevention: Involves minimizing risk factors such as medication use, sensory deficits, and promoting sleep hygiene.
  • First-Line Treatment: Non-pharmacological measures are preferred, with medications used only as a last resort.

Dementia

  • Features: Insidious onset of cognitive decline affecting memory, language, and daily functioning.
  • Treatment: A comprehensive approach including pharmacological (cholinesterase inhibitors), social, and family interventions.

This study guide consolidates critical content for the NR601 final exam, focusing on essential topics in glucose metabolism disorders, urology and aging, elder abuse, Alzheimer’s disease, delirium, and dementia.