Pain Management Options Based on the category of illness and their stage level of sickness
Pharmacists, podiatrists, dentists and dental hygienists as well as optometrists and ophthalmologists are asked to examine diabetics for the most common diabetes-related eye diseases: retinopathy, double vision, vision fluctuations, cataracts, macular edema and ocular nerve palsy.
A comprehensive diabetic eye exam takes into consideration the following factors: visual acuity, visual fields, pupillary reaction, intraocular pressure, cranial nerves, a slit-lamp exam and a dilated retinal exam.
Diabetes is the condition most responsible for new incidence of blindness in adults aged 20 to 74 years of age. Retinopathy triggers 12,000 to 24,000 new cases annually. Diabetics are encouraged to care for their eyes by undergoing a complete vision exam yearly, including a dilated eye test with intervention if retinopathy is discovered.
Diabetics are 25 times more likely to develop blindness than those not afflicted with the condition. Particularly, diabetics who use cigarettes, eat poorly and do not control their blood sugar levels are at greater risk for cultivating eye conditions.
Because diabetes causes patients to heal slowly from wounds or injuries overall, eye conditions, including minor corneal scratches, ought to be taken seriously by optometrists and ophthalmologists.
Diabetes retinopathy is a diabetic eye complication caused by excess blood sugar damaging the blood vessels of the eye, leading to breakdowns, leaks or blockage.
This may lead to retinal hemorrhage and compromised delivery of oxygen to the retina, which may translate into the growth of deformed vessels. Such vessels are delicate and can break easily, resulting in the loss of vision.
One out of every 12 diabetics aged 40 years and older suffer from retinopathy. Research finds that aspirin use is safe in use for diabetics with retinopathy and the condition is treatable and preventable.
Poor blood sugar level control and a long history of diabetes can raise the risk of senior patients with type 1 and type 2 diabetes developing retinopathy. Thus, self-management of blood sugar, blood pressure and lipid can reduce or delay this risk by 76 percent in diabetics.
Early detection of retinopathy can cut back on the risk of retinopathy-related vision loss by 90 percent in diabetics. Still, half of all diabetics are not having their eyes examined or are found to have developed too advanced a stage of these eye conditions to be treated in time. Additionally, diabetics are in danger of contracting glaucoma and cataracts.
Enhanced therapy lessens the presence of retinopathy by 27 percent and retinal laser photocoagulation surgery can cut the risk from the most aggressive form of the illness, also known as proliferative diabetic retinopathy (PDR), to at least 4 percent.
Optometrists and ophthalmologists can supply such vision aids as simple hand magnifiers or optical devices for diabetics who have lost their sight to retinopathy. Eye care professionals can also seek to provide a comprehensive suite of care and services to allow visually-impaired diabetics to keep their dignity and control their diabetes.
Senior diabetics are at risk for developing cataracts, which represents a clouding of the eye lens with aging being the main cause of this condition. The lens focuses images that enter the eye onto the retina. A clouding would mean limited vision and more sensitivity to glare. More than half of seniors have cataracts.
Glaucoma is a condition damaging the optic nerve. The nerve carries images in the retina to the brain so obstruction of this transfer means the development of blind spots or field loss, which eventually leads to complete blindness.
A dilated eye exam, visual field testing, intraocular pressure testing and other exams provide a view of the optic nerve and can detect glaucoma early, making treatment possible.
With patients aged 40 years or older, about 2.2 million suffer from glaucoma while another 1.1 million don’t know they have the illness. African-American seniors are two times likely to develop glaucoma as their white peers.
Diabetics may complain about the onset of double imagery because of damage to the nerves from the brain to the eye. This warrants an immediate visit to the optometrist or ophthalmologist.
Double vision, an ocular complication, can be mistaken by a diabetic or a specialist other than an optometrist or ophthalmologist as stroke or another neurological condition, which can needlessly lead to radiological exams.
This complication may be due to mononeuropathy or damage to a single nerve. As a solution, third-nerve palsies take place with pupillary sparing in 80 percent of these cases. Most diabetics suffering from this condition experience healing within two to three months and double vision can be managed with special lenses.
Poor control of blood sugar levels can lead to fluctuation in vision. Poor blood sugar level control can cause fluid imbalance in the lens, which triggers the fluctuations.
When blood sugar levels are raised, the lens grows thicker and the resulting changes in vision may lead to nearsightedness or farsightedness. When blood sugar levels drop, the lens returns to its normal size. With inconsistent blood sugar level control, diabetes with glasses will find it hard to determine the best lenses to wear for their changing eyesight.
The NIH-CDC workgroup instructs specialists to ask diabetics the following questions about their eye health:
–Whether they are aware of the connection between diabetes and eye health, the risk of diabetic retinopathy, its responsibility for blindness and avoidance through sound blood sugar level control;
–Whether they know that, as diabetics, they are at risk for developing such eye conditions as cataracts and glaucoma and such symptoms as fluctuations in vision, double vision or dry eye;
–When they have last had a comprehensive dilated eye exam and whether they have one yearly and a regular eye screening to avoid blindness due to diabetic retinopathy;
–If they have reported eye symptoms to their primary care physicians and have a prescription for eyeglasses, contact lenses or vision aid, and;
–How often and long do they suffer from these eye symptoms and whether they report any changes in eyes or visions such as blurriness, spots, redness or pain to their primary care physicians, optometrists or ophthalmologists.
Pharmacists, podiatrists, optometrists and ophthalmologists as well as dentists and dental hygienists are asked to check their senior diabetics for the following diabetes-related oral health conditions: changes in teeth, periodontal disease and oral candida (thrush).
A comprehensive oral exam will take teeth, gums, periodontal probing, intraoral lesions, infections or masses and insufficient saliva flow into consideration.
Diabetes can cause changes in the teeth and mouth. Dentists and dental hygienists are most concerned about how diabetes affects the health of gums and periodontal tissues.
Poor blood sugar level control is linked to gingivitis and other periodontal conditions. Symptoms of diabetes and dental illness include a neurosensory disorder known as burning mouth syndrome, problems in taste, abnormal wound healing and a fungal infection known as candidiasis.
Senior diabetics with oral health problems will note that they have a fruity breath, caused by a colorless, flammable, liquid substance known as acetone (a simple ketone used in nail polish), frequent xerostomia or dry mouth or a change in the thickness of their spit or saliva. This is dangerous as dry mouth can usher in an increase of dental decay.
Besides fruity breath, thickness in saliva, dry mouth and possible dental decay, xerostomia is also characterized by gum disease, especially red, swollen and bleeding ones or gums pulling from the teeth, pus between gums, loose teeth or change in bite or tooth position and candidal infection or thrush.
Dental problems in senior diabetics are connected with other discoveries such as a vast loss of fluids through excess urination, infection, a change in connective tissue and function, neurosensory malfunction, microvascular changes, drugs causing dry mouth and increased sugar concentration in saliva.
Cigarette use worsens these oral conditions, researchers say. However, often senior diabetics focus on other problems or complications tied to diabetes and oral care can be neglected. Aside from blood sugar level control, they say, sound oral hygiene can alleviate all of these problems.
Senior diabetics are two to three times more likely than non-diabetics to develop periodontal disease, such as periodonititis. Periodontal disease is an infectious, chronic, inflammatory illness that damages connective tissue and bones supporting teeth and leading to tooth loss.
Among individuals with type 1 and type 2 diabetes, periodontal disease is more likely to develop, especially more quickly and in a much more severe form than in non-diabetics. Research finds a powerful association between diabetes and periodontal disease.
Not only are diabetics more prone to periodontal disease but also this condition can make blood sugar level control harder. Oral care that includes treating periodontal disease may help diabetics control their blood sugar levels.
Research has found a relationship between an individual’s resistance to insulin and inflammatory disease. Swollen periodontal tissue, which can be as large as an adult’s palm in size, contains blood vessels and can be subject to ulcers. This infection may poison the blood with bacteria.
Such infection can cause the liver to produce “acute-phase proteins such as C-reative protein (CRP), serum amyloid A, and fibrinogen.” The level of these proteins can be raised in the blood of patients with periodonititis and have been known to damage other vital organs.
As a result, periodontal disease can ultimately lead to the development of other such illnesses as diabetes mellitus and heart disease.
The NIH-CDC workgroup says this can all be avoided by using periodontal probing by a dentist or dental hygienist as a diagnostic tool that can measure diabetics’ reactions to treatment with the following questions:
–Whether they are aware of the connection between poor control of blood sugar levels and gum disease and that oral care can control diabetes;
–Whether they practice sound dental hygiene such as brushing teeth after eating, flossing at least once daily and proper denture management;
–Whether they conduct monthly oral self-exams and contact their dentists or dental hygienists if they find signs of infection such as sore, swollen or bleeding gums, loose teeth and ulcers, and;
–Whether they experience symptoms that suggest infection such as bad taste, bad breath or pain and can determine when problems require medical attention.
Type 2 diabetics are twice to four times as likely to suffer from cardiovascular disease or endure a stroke than non-diabetics. Heart disease is the main cause of death for diabetics.
However, research in recent years have shown that there are clinical approaches that can prevent or delay the onset of complications of diabetes as well as the illness itself.
Some studies, such as the national Diabetes Control and Complications Trial (DCCT), demonstrate that blood sugar level control decreases the risk of microvascular disease in type 1 diabetics.
Namely, blood sugar level control translated into a 76 percent decrease in eye conditions, including 63 percent in retinopathy, a 54 percent drop in nephropathy and a 60 percent plunge in neuropathy.
The United Kingdom Diabetes Study (UKPDS) demonstrated that type 2 diabetics enhanced blood sugar level control from an A1C of 7.9 percent to that of 7.0 percent, leading to a decrease in the risk by 25 percent for microvascular disease; 17 percent to 21 percent for retinopathy, and; 24 percent to 33 percent for albuminaria, a disease in which the protein, albumin, is present in the urine.
Additionally, lower A1C also cut down the risk of macrovascular disease with a 16 percent decrease in heart disease and a 24 percent decrease in cataracts. The UK study also finds low blood sugar level control not only decreased diabetic complications but also led to blood pressure control.
The study concluded that “tight blood pressure” lessened the risk of retinopathy progression by 34 percent; vision loss by 47 percent; diabetes-related deaths by 32 percent; microvascular disease by 37 percent; heart failure by 56 percent, and; stroke by 44 percent.
Moreover, clinical trials like the Appropriate Blood Pressure Control in Diabetes Trial (ABCD) and Heart Outcomes Prevention Evaluation Study (HOPE) also demonstrates that an ACE inhibitor decreases the risk of heart failure, stroke or cardiovascular deaths by 25 percent to 30 percent in patients with type 2 diabetes and delays the development of kidney damage of diabetes.
Aside from pharmacists, podiatrists, optometrists and ophthalmologists, dentists and dental hygienists must confer with their senior diabetics for the following “drug management” issues: inappropriate drug choice, “underdosage, overdosage,” bad drug reactions and “drug interactions.”
Specialists must consult with their senior patients about strategies for managing their medications such as in their “use, monitoring treatment, self-treatment, over-the-counter (OTC) medications, selecting and using a blood sugar meter, cost control and coordination of care.”
Individuals most at risk for drug-related issues include those with severe long-term illnesses, take five or more medicines and those who see a variety of specialists. For professionals, this means complete reviews of drugs and their records, training of senior patients to comply with drug regimens and assessments of the way in which patients react to therapy to intervene properly and to coordinate and maintain plans of care.
The latest drugs and medical technologies give senior patients and physicians choices for treating diabetes and its complications. If not properly administered, however, they can lead to serious disease, disability or death.
Research in 2001 found that improper use of drugs nationally costs $177 billion a year in hospital re-admissions, extra therapy and visits to the doctor’s office, a boost from $76.5 billion in 1995.
Worse still, research averages that 218,000 drug-related deaths per year are due to misused drugs. Aside from inappropriate drug choice, “underdosage, overdosage,” bad drug reactions and “drug interactions,” researchers also examine untreated illnesses and drugs with no particular treatment goal.
Research also finds that over half of patients with chronic illness do not take their drugs appropriately. More than 60 percent of diabetics do not control their blood sugar levels. Of all high blood pressure and cholesterol patients, about 65 percent and 49 percent consecutively, are not able to reach their intended health goals.
As a result, researchers advise specialists to urge their senior patients to comply consistently with proper drug use directives and minimize lethal drug interactions and to track their conduct. These actions maximizes health outcomes and results in savings to the healthcare system, they say.
Diabetics ought to forge a relationship with a pharmacist who can supervise drug regimens, advise on how to self-administer drugs and inform them about other methods of controlling their diabetes.
The NIH-CDC workgroup prods specialists, especially pharmacists, to ask diabetics the following questions about their drug management strategies:
–Whether their drug routines are individualized for the best times to take these medications, avoiding side effects and poor drug interactions;
–Whether they use compliance aids, the proper dosage forms and a drug delivery system to effect proper drug use;
–Whether they are using nonprescription treatments such as vitamins, minerals, herbals, nutritional supplements or skin-care products, (Research finds that more than 57 percent of diabetics use alternative therapies.);
–How serious and urgent are their complaints, what is the appropriate level of self-administration warranted for the drugs they take and what warnings are there for the drugs they use;
–How much is a follow-up or a referral to another specialist warranted;
–Whether they use a blood sugar monitoring device and are properly trained to use it, knowing about the results, the correct actions to take and the appropriate times to seek help, and;
–Whether they know how to lower the costs of drugs and supplies through private insurers, prescription drug programs, Medicare and Medicaid, generic medications and coverage for referrals to other specialists.
Coordination of Care
Researchers acknowledge that comprehensive diabetic care is riddled with problems as it is provided by several specialists in different types of facilities. There may be changes in drug regimens when senior patients visit their physicians or at the time of severe illness or hospital stays.
When a patient stricken with numerous complications of diabetes and taking a cocktail of drugs to treat them, including over-the-counter medications, herbals and supplements, they and their specialists must practice careful self-administration and management.
Research shows that collaborative drug therapy management (CDTM), given by pharmacists and other specialists, revealed the myriad problems faced by patients’ in 65 percent of their drug routines.
Still, more research found that CDTM ended in decreased incidence of disease as well as lower costs linked to fewer doctors’ visits, emergency hospital visits and hospital stays.
Through coordinated care, all the specialists in a medical team as well as the patient can take advantage of a single point of contact to provide the appropriate drug regimens, instructions and essential tracking for effectiveness and drug interactions.
As a consequence, the NIH-CDC workgroup urge specialists to commit to the following in promoting the comprehensive diabetic care approach to addressing a patient’s medical needs:
–Encourage medical leadership to set up policies and procedures for quality diabetic care in a strategic plan;
–Recruit and consult with a designated diabetes coordinator and the care team;
–Instruct patients to perform self-management drug actions per the NDEP and ADA protocols;
–Rework the healthcare delivery system to allow for the use of registries and tracking mechanisms for appointments;
–Review charts for the office visits in the same system;
–Manage cases with a care coordinator using the same system;
–Make and back up medical decisions using flowsheets and electronic health records, and;
–Build relationships with local community organizations.
American Academy of Ophthalmology, http://www.aao.org
American Academy of Optometry, http://www.aaopt.org
American Academy of Periodontology, http://www.perio.org
American Association of Clinical Endocrinologists, http://www.aace.com
American Association of Diabetes Educators, http://www.diabeteseducator.org
American College of Clinical Pharmacy, http://www.accp.com
American Dental Association, http://www.ada.org
American Dental Hygienists Association, http://www.adha.org
American Dietetic Association, http://www.eatright.org
American Optometric Association, http://www.aoa.org
American Pharmacists Association, http://www.aphanet.org
American Podiatric Medical Association, http://www.apma.org
American Public Health Association, http://www.apha.org
American Society of Health-System Pharmacists, http://www.ashp.org
HRSA Health Disparities Collaboratives, http://www.healthdisparities.net
National Association of Chain Drug Stores, http://www.nacds.org
National Community Pharmacists Association, http://www.ncpanet.org
National Diabetes Information Clearinghouse, http://diabetes.niddk.nih.gov
National Eye Institute, http://www.nei.nih.gov
National Heart, Lung and Blood Institute, http://www.nhlbi.nih.gov
National Institute of Dental and Craniofacial Research, http://www.nidcr.nih.gov
National Optometric Association, http://www.natoptassoc.org
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