Case Report: Type 2 DiabetesMellitus for the Elderly with Less Family Support

CASE REPORT Mrs. R, 65 years old came to Puskesmas B with complaints of fatigue during activities accompanied by weakness since 1 week ago. The patient has been diagnosed with Diabetes Mellitus since 2 years ago, but the patient admitted that she sometimes went to the health center once every 2 or 3 months depending on her complaints. According to the patient’s acknowledgment, initially complaints of fatigue were felt rarely but gradually became more frequent and appeared during light activities and felt continuously. Complaints are not accompanied by blurred vision or numbness.

Mrs. R took the drugs metformin and glimepiride if she had just gone to a health professional when she had a complaint. Additionally, Mrs. R admitted that because of the complaint of feeling weak, Mrs. R often consumed date juice 3 X 1 spoon every day. Mrs. R is often given explanations by health workers to maintain her diet, but according to her she still cannot regulate her diet properly. Mrs. R still can be active and currently the patient is active as a housewife. Every Saturday, Mrs. R follows the exercise program from the village, namely elderly gymnastics, while on other days Mrs. R does not do sports, and only does home activities. Mrs. R denied smoking history, denied drinking alcohol, and denied taking drugs. Mrs. R currently lives with her husband and one grandson.

BIOLOGICAL AND PSYCHOSOCIAL DIAGNOSES
A holistic diagnosis was formulated since the patient was having a complaint of fatigue during activities accompanied by weakness since 1 week ago, and she is worried that her condition would worsen, wishes that her pain can be relieved and her condition controlled in order to carry out her normal daily activities. The patient is considered as an elderly overweight lady, with uncontrolled diet with little physical activity.
Diagnosis was made based on patients' history, physical and lab examinations, which were conducted both at the Puskesmas and during home visits. Though she denied any classical symptoms of diabetes, a current blood sugar of 300 mg/dl and risk factors of being overweight, with uncontrolled diet and physical activity support the diagnosis of type 2 diabetes mellitus (T2DM). In the psychosocial diagnosis, the patient is deeply concerned that the disease will get worse. She has no prior awareness or knowledge of diabetes, referring to only her awareness that illnesses will take longer to heal. The patient assumes this disease is a disease that does not need routine treatment. Currently, the patient has seven children, and the first to fifth children are married, the sixth and seventh children are not married but live in different cities with the patient.

Family Assessment Tools
Information:

Social
Good interaction between family members, patient participation in active community activities. Currently, the patient spends time at home with family members.

Culture
Satisfaction or pride in good culture, this can be seen from daily interactions both in the family and in the environment, and many cultural traditions are still followed, including using Javanese language, manners and politeness.

Religious
The application of the teachings is also good; this can be seen from the sufferer and their family who routinely pray five times a day; the patient also wears headscarves and the patient's husband often prays at the mosque.

Economic
This family is classified as middle class; primary needs can be met, secondary needs and economic plans are adequate; a priority scale is needed to meet the needs of life

+ Educational
Low education of family members, patient and husband are elementary school graduate's

+ Medical
In seeking health services, families use Puskesmas services and use the Jamkesmas card (BPJS) for treatment. Patient claims that they will only seek treatment if there are complaints, and patient rarely does health checks regarding their illness.

FORMULATION OF THE PROBLEM
The issue in this case is multifaceted, encompassing not only the clinical aspects of T2DM and overweight, but also the psychosocial aspects of the patient's ability to self-manage her disease. Type 2 diabetes is a debilitating condition that causes cognitive and functional deficits as well as dependency, putting a considerable strain on healthcare systems as well as social services. Long-term care is required for T2DM, which places a strain on personal, family, and public resources. Type 2 diabetes, on the other hand, is a self-managing illness in which patients can meet 99 percent of their own needs 1 .
Diabetes management in older individuals is difficult since there is such a wide range of clinical presentations, psychosocial milieu, and limited resource availability in this population. Both glycemic goals and diabetes management can be influenced by a person's living situation and the level of accessible social support. Diabetes management varies depending on where older persons live (i.e.,whether they are community welling or live in an assisted-living facility or a nursing home) 2 .
Because the senior population is physiologically diverse, a full assessment, which incorporates functional factors in the decision-making process, is required 3 . The elderly have the highest risk of hypoglycemia as a consequence of diabetes treatment among adults of all ages. The loss in body mass associated with aging and frailty syndrome might result in a significant reduction in the demand for anti-diabetic medications, both oral and insulin. Similarly, as kidney function declines with age, the doses of medicines that stimulate insulin production or insulin levels that have been successfully regulating the course of the illness may become excessively high 4 .

DISCUSSION
Comorbidities (geriatric syndromes) such as cognitive impairment, depression, functional disability, falls and fractures, polypharmacy, chronic pain, and urine incontinence are all increased by aging and diabetes. If doctors are unaware of these coexisting disorders, they may recommend treatment that is too complicated for a patient with cognitive impairment, or they may overlook an opportunity to treat depression, which can lead to medication nonadherence and social isolation 2 .
Overweightness, obesity, inheritance, and a lifestyle that includes smoking and alcohol consumption are the leading causes of diabetes. Type 2 diabetes is caused mostly by a person's lifestyle and eating habits, which results in overweightness and obesity. Type 2 diabetes is connected to gene abnormalities that are handed down via the family's genetic line and has a hereditary component 5 . Geriatric patients are different from other young adult patients, both in terms of health concepts and in terms of causes, travel, and symptoms and signs of the disease so that, the procedure for diagnosis in geriatric patients is different from other populations. Dietary behavior is linked to a higher mean fasting blood sugar level, which was statistically significantly correlated. The high consumption of sweets is a crucial issue that can be targeted to enhance diabetes control in Malay patients 1 .

DIABETES MANAGEMENT IN ELDERLY
In the elderly, metabolic control has been demonstrated to be improved by dietary education programs. Because these diets frequently have low protein content, they should be avoided by elderly citizens to avoid hypoglycemia and malnutrition 3 .
One of the pillars of T2DM management is physical activity. Physical activity, especially multicomponent activity (aerobic, resistance, flexibility, and balancing), has been shown to improve not just glucose control, but also functional independence, self-esteem, and quality of life in diabetic seniors. Resistance exercise to increase muscle mass is an important part of preventing and treating T2DM in the elderly, and it is the preferred treatment option for fragile people. Moderate to high-intensity activities, contrary to popular opinion, are more effective for glycemic control and are generally safe for the elderly 3 .
Treatment for older people should generally begin with low-dose antidiabetic medicines with a low risk of hypoglycemia (especially metformin and dipeptidyl peptidase-4 inhibitors (DPP-4I)), with a gradual increase in dose and monitoring of response after each increase. Drugs linked to a high risk of hypoglycemia such as sulfonylureas with insulin, especially postprandial and combinations, should be avoided as much as possible. Several studies have proved its safety in the treatment of elders. Its benefits include its effectiveness in lowering HbA1c levels, positive effects on body mass and lipid profiles, and the fact that metformin is a medicine that improves prognosis 3, 4, 6 .

EDUCATION
Diabetes self-care was found to be significantly linked to the patients' diabetes knowledge in older individuals. When compared to patients with low diabetes awareness, individuals with good and adequate diabetes knowledge had better diabetic self-care. Education is a critical component that must be prioritized. This investment will ensure that the high expenses associated with diabetic complications are reduced over time. Patient education increased patient understanding and had a good effect on metabolic management, according to two meta-analyses 1 .
Evidence revealed that a patient's self-efficacy and motivation, together with proper knowledge, can accurately predict behavioral improvements. Motivation and selfefficacy (confidence) were critical in forming a change intention. An individual might attain his or her specific goals with the idea that they will retain the improvements if they act with intention and receive suitable knowledge 7 . Meanwhile, a 2017 study looked into T2DM patients' preferences for Diabetes Self-Management Education (DSME). Patients prefer to be trained in fewer sessions and for shorter periods of time, according to research. This suggests that the substance of educational sessions, as well as how they are tailored to patients' needs, are more essential than the quantity and duration of the educational sessions 8 .

FAMILY SUPPORT
Families are one of the key providers of social support for adults with T2DM, according to systematic reviews, and families actively participate in the health treatment of adults and elders. When patients have blood relatives, care is most typically delivered by a family member, not just because of their existing link, but also since this is a cultural responsibility. Social support can be thought of as a personal dimension of family ties, i.e. something that happens as a result of them, regardless of the family structure 9 .
Patients might benefit from the assistance of friends, family members, nurses, and physicians. The findings of this study are comparable with those of other studies conducted across the world, indicating that family support and diabetes selfcare have a positive link. When compared to those who had no caregiver or were cared for by others such as friends or nursing home personnel during their illness, older patients who were cared for by their family showed higher levels of diabetic self-care 1 . Adherence to diet and exercise were shown to be higher in individuals who had family support than in those who did not 7 .
Family members' information and roles in program activities like providing emotional support for problemsolving and assisting patients in resolving emotional distress, or providing information and roles to facilitate, accommodate, remind, motivate, and partner with behavior change and task completion were included in many studies. Family members were included in an intervention program in some of the studies included in this assessment. Family members may be able to assist patients in strengthening self-management therapies and extending the duration of the intervention's effectiveness 10 .
Religion and spirituality of the members of a family can influence both positively and negatively the approach of the family facing a problem; in other words, it can interfere with the patients' ability to deal with a particular pathology. The spirituality and religion can still influence family habits, values and health care to the patient 11 .
One technique to acquire a complete picture of patients as family members is to look at their family profiles. In addition to risk assessment, family history data can be used to personalize health messaging, which may be more effective in promoting healthy behaviors than standardized messages 12 .

RISK OF DEPRESSION
Diabetes has been linked to an increased incidence of depression. Poor blood sugar control, a rigorous diet, and physical activity requirements, as well as medication, may raise the risk of depression in diabetic patients. Chronic stress has been found to promote hyper-activation of the hypothalamic-pituitary-adrenal axis as well as an increase in cortex, which has been identified as a critical mechanism for understanding the clinical linkages between diabetes and depression 13 .
According to Goldney et al., diabetics have a higher prevalence of depression than non-diabetics, with about 24 percent of diabetics having depression compared to 17.1 percent of non-diabetics. In a systematic study of depression in diabetics, prevalence of depression in diabetics ranged from 8.5 percent to 27.3 percent. According to Gavard et al., depression, on the other hand, has been related to a 60% increase in the chance of developing type 2 diabetes 14 .
The high rate of comorbid depression in diabetic patients could be attributed to the condition's psychosocial load, a lack of social support, awareness of having a chronic disease with its accompanying issues and limits, and the resulting psychological burden. Furthermore, poor diabetes control measures such as glycemic control, retinopathy, nephropathy, neuropathy, microvascular issues, and sexual dysfunction in patients with diabetes are connected to comorbid depression 6 .
Depression treatment, both psychological and pharmaceutical, has been linked to considerable clinical benefits in diabetic patients. These benefits occur not just in mood but also in adherence to T2DM diet and treatment regimens, affecting glucose control, lowering chronic complications, and enhancing quality of life 15 .
According to multivariate analysis, those who were overweight, had poor physical capabilities and exercise, and had multiple other ailments have a higher chance of depression, but those who took metformin had a decreased risk of depressive symptoms 6 .
Activating and empowering efforts are aimed at assessing whether physicians call family meetings to discuss a patient's health problem or problems that arise as a result of the problem, provide family counseling to address the patient's health issues, improve the family's ability to manage the patient's health issues, boost the family's ability to manage the patient's health issues, increase the family's understanding of how to manage the patient's health issues, assess family coping, and determine the impact of the patient's illness on the family 12 . The family approach in the management of diabetes mellitus helps identify factors that influence patients clinically, personally, and psychosocially through family involvement. With this approach, management will be more comprehensive and is expected to improve the patient's quality of life.