Diabetes mellitus is a group of metabolic diseases characterized by hyperglycemia-a result of defects in insulin secretion, insulin action, or both. The chronic hyperglycemia of diabetes is associated with long-term complications involving various organs, including the eyes, kidneys, nerves, and cardiovascular system.1 Rehabilitation professionals may work with a person with diabetes because of a problem related to these complications and/or may need to take the complications into account during rehabilitation.

Symptoms of marked hyperglycemia may include polyuria, polydipsia, polyphagia, weight loss, blurred vision, and increased susceptibility to certain infections. Hyperglycemia may cause life-threatening situations of diabetic ketoacidosis and hyperglycemic hyperosmolar nonketotic syndrome.1

Long-term complications of diabetes include retinopathy with potential vision loss; nephropathy, which can lead to kidney failure; peripheral neuropathy, which increases risk of foot ulcers, amputations, and Charcot joints; and autonomic neuropathy with cardiovascular, gastrointestinal, and genitourinary symptoms and sexual dysfunction. People with diabetes have an increased incidence of cardiovascular, peripheral arterial, and cerebrovascular diseases. Hypertension and dyslipidemia often occur in those with diabetes.

The term borderline diabetes is no longer used; rather, the term prediabetes is used when a person has impaired fasting glucose (IFG) and/or impaired glucose tolerance (IGT). In these situations, a person has elevated glucose levels that do not yet fall into the ranges that give the diagnosis of diabetes. When a person has IFG or IGT, improvements in glucose metabolism may be achieved with weight reduction, increased physical activity/exercise, and/or oral glucose-lowering agents.1 If a person with IFG or IGT is in rehabilitation for any reason, there is an opportunity to foster healthy lifestyle changes by encouraging increased activity within the rehabilitation program. For example, a person with IFG or IGT participating in physical or occupational therapy may be encouraged to ride a stationary bike in the clinic prior to or after his or her scheduled skilled therapy service. Once a person has had positive experiences with exercise, he or she may be able to incorporate more activity into his or her life to delay or prevent the onset of diabetes.

CLASSIFICATION OF DIABETES MELLITUS

As previously mentioned, IFG and IGT are included in the diagnosis of "prediabetes." Women who develop diabetes during pregnancy have a diagnosis of gestational diabetes. Following the pregnancy, blood glucose levels may return to normal. If they remain elevated, she may have type 1 or type 2 diabetes. Most people with diabetes have 1 of 2 major forms: type 1 or type 2 diabetes. Type 1 diabetes, accounting for 5% to 10% of those with diabetes, is from [beta]-cell destruction leading to absolute insulin deficiency. Type 1 diabetes was previously called insulin-dependent diabetes, type I diabetes, or juvenile-onset diabetes. Because these terms are no longer used in the United States, rehabilitation professionals should use the term type 1 diabetes, which may develop during infancy, childhood, adolescence, or adulthood (even in an aging adult in his 60s, 70s, or 80s). Most people with diabetes have type 2 diabetes, accounting for 90% to 95% of all cases. Previously, type 2 diabetes was called non-insulin-dependent diabetes, type II diabetes, or adult-onset diabetes. Again, since these terms are no longer acceptable in the United States, rehabilitation professionals should use the term type 2 diabetes. Type 2 diabetes often develops during adulthood, although there is an increasing number of children and adolescents having a diagnosis of this diabetes, and is associated with obesity and physical inactivity. The onset of type 2 diabetes can be delayed or prevented with modest reductions in weight (5%-10%) and increases in physical activity. There are other forms, but these are the most common types of diabetes.1

DIAGNOSTIC CRITERIA FOR DIABETES MELLITUS

Diabetes can be diagnosed from elevated fasting blood glucose levels or elevated levels during an oral glucose tolerance test (OGTT). Normal fasting plasma glucose (PG) is less than 100 mg/dL and normal PG during an OGTT is less than 140 mg/dL 2 hours after ingesting the glucose load. "Prediabetes" is diagnosed by a fasting PG of 100 to 125 mg/dL (IFG) or a 2-hour post-glucose load level of 140 to 199 mg/dL (IGT). When a person has a fasting PG of 126 mg/ dL or more, or 2-hour post-PG load of 200 mg/dL or more, confirmed on a second occasion, he or she has a diagnosis of diabetes. In 2010, "Diagnosis of prediabetes" was changed to "Categories of increased risk for diabetes." This includes IFG, IGT, and a hemoglobin A_1c(A_1c) of 5.7% to 6.4%. A normal A_1c level is less than 5.7% and diabetes is diagnosed if the A_1c is 6.5% or more. These values are presented in Table 1.1

Table 1. Summary of normal plasma values, categories for increased risk of diabetes, and plasma values for diabetes

DIABETES AND AGING ADULTS

There are natural changes that occur in an adult within the aging process. A person with diabetes may have additional changes, including cardiovascular, cardiopulmonary, musculoskeletal, ophthalmologic, renal, neurological, gastrointestinal, and cognitive. The combination of aging and diabetes may create many problems and considerations for the rehabilitation professional. These changes are addressed in "Aging and Diabetes."

People with diabetes are treated with many medications, oral and injected. These medications should be taken into account when working with a person with diabetes in rehabilitation. The article "Medications: The Impact of Diabetes Medications in Rehabilitation" provides a review of medications used to manage blood glucose levels, medications an aging adult may be taking that may disrupt glucose homeostasis, and rehabilitation implications of other common drugs used by a person with diabetes.

Medical nutrition therapy for aging adults with diabetes should be individualized on the basis of the person's needs and abilities. The foods a person eats can immediately affect blood glucose and, in the long term, affect his or her overall health. Rehabilitation professionals should have a basic understanding of nutrition principles and should encourage healthy eating. "Promoting Healthy Eating Among Older Adults With Diabetes" provides information on healthy eating, carbohydrates, and other nutritional considerations for older adults with diabetes.

Physical activity is a cornerstone of the treatment of people with diabetes, providing short- and long-term benefits. Rehabilitation professionals should have knowledge of the exercise prescription for a person with diabetes as well as an understanding of the impact of diabetic complications and comorbidities on exercise. "Physical Activity: Exercise Prescription for the Older Adult With Type 2 Diabetes" reviews the benefits of exercise, the recommendations for exercise for the older adult with type 2 diabetes, and considerations due to comorbid conditions.

Many older adults with diabetes have diabetes complications that may impact their exercise and general activity. Knowledge of these complications will help to minimize risk and promote greatest benefit with exercise. "Risks and Challenges With Exercise and Physical Activity for People With Diabetes: The Impact of Diabetes-Related Complications" presents information about the potential risks associated with exercise, including hypoglycemia and hyperglycemia, and the implications of microvascular and macrovascular complications of diabetes during the rehabilitation of older adults with diabetes.

People with diabetes can have an increased incidence of some musculoskeletal disorders and may present with musculoskeletal problems that impact their activity. Rehabilitation professionals should be aware of common disorders present in those with diabetes and the implications of these disorders with therapy interventions. "Common Musculoskeletal Disorders in Older Adults With Diabetes" provides an overview of common musculoskeletal disorders in the older adult with diabetes and the impact of musculoskeletal conditions on the ability of a person with diabetes to be active.

Aging adults with diabetes have an increased risk of foot problems that could result in open wounds and amputation. Rehabilitation professionals will benefit from knowledge of the impact of diabetes on the foot, strategies to minimize complications, and management of wounds. "Foot Care for Patients With Diabetes" reviews the effects of diabetes on the feet and management guidelines including wound healing and patient education.

Many older adults with diabetes have vision loss. Management of diabetes, compounded with vision loss, presents a challenge on its own. There are many strategies and adaptive equipment that can benefit people with diabetes. Rehabilitation professionals may be involved in providing adaptive equipment, instruction in its use, and need to work with adaptive equipment during rehabilitation. "Vision Rehabilitation and the Client With Diabetes" provides information about vision loss and diabetes, teaching strategies for those with vision loss, and an overview of equipment that is available for the management of diabetes for the older adult with vision loss.

- Karen Kemmis, PT, DPT, MS, CDE

SUNY Upstate Medical University, Syracuse, New York

REFERENCE