Chiaisson JL, Josse RG, Hunt JA, Palmason C, Rodger NW, Ross SA, Ryan EA, Tan MH, Wolever JM 1994 The ef®cacy of acarbose in the treatment of patients with non-insulin dependent diabetes
Trang 1Balant L, Zahnd G, Gorgia A, Schwarz R, Fabre J (1973)
Pharma-cokinetics of glipizide in man: in¯uence of renal insuf®ciency.
Diabetologia, 9, 331±338.
Balfour JA, Faulds D (1998) Repaglinide Drugs and Aging, 13,
173±180.
Baron A, Neumann C (1997) PROTECT interim results: A large
multicenter study of patients with Type II diabetes Clinical
Therapy, 19, 283±295.
Bayer (1998) Precose 1 (acarbose) Prescribing information Bayer
Corporation, West Haven, CT, USA.
Beck-Nielsen H, Hother Nielsen O, Andersen PH, Pederson O,
Schmitz O (1986) In vivo action of glibenclamide Diabetologia,
29, 515A (abstract).
Berger S, Strange P (1998) Repaglinide, a novel oral hypoglycemic
agent in Type 2 diabetes: a randomized, placebo-controlled,
double-blind, ®xed-dose study Diabetes, 47 (Suppl 1), 496
(abstract).
Berger W (1985) Incidence of severe side effects during therapy
with sulfonylureas and biguanides Hormone and Metabolic
Research, 17 (Suppl 15), 111±115.
Bergman U, Boman G, Wilholm BE (1978) Epidemiology of
adverse drug reactions to phenformin and metformin British
Medical Journal, 2 (6135), 464±466.
Bristol-Myers Squibb (1995) Glucophage 1 (metformin
hydrochlor-ide tablets) 500 mg and 850 mg Prescribing information
Prin-ceton, NJ: Bristol-Myers Squibb Co.
Charbonnel B, LoÈnngvist F, Jones NP, Abel MG, Patwardhan R
(1999) Rosiglitazone is superior to glyburide in reducing fasting
plasma glucose after 1 year of treatment in Type 2 diabetes.
Diabetes, 48 (Suppl 1), Poster 494 A114.
Chehade JM, Mooradian (2000) A rational approach to drug therapy
of Type 2 diabetes mellitus Drugs, 60, 95±113.
Chiaisson JL, Josse RG, Hunt JA, Palmason C, Rodger NW, Ross
SA, Ryan EA, Tan MH, Wolever JM (1994) The ef®cacy of
acarbose in the treatment of patients with non-insulin dependent
diabetes mellitus Annals of Internal Medicine, 121, 928±935.
Chissold SP, Edwards C (1988) Acarbose: a preliminary review of
its pharmacodynamic and pharmacokinetic properties, and
ther-apeutic potential Drugs 35, 214±243.
Coniff RF, Shapiro JA, Seaton TB, Bray GA (1995) Multicenter,
placebo-controlled trial comparing acarbose (Bayg 5421) with
placebo, tolbutamide, and tolbutamide-plus-acarbose in
non-insulin-dependent diabetes mellitus American Journal of
Medi-cine, 98, 443±451.
Cooper GJS, Willis AC, Clark A, Turner RC, Sim RB, Reid
KB (1987) Puri®cation and characterization of a peptide
from amyloid-rich pancreas of Type 2 diabetic patients.
Proceedings of the National Academy of Sciences USA, 84,
8628±8632.
Cruetzfeldt W, Nauck M (1996) Gastric emptying, glucose
responses, and insulin secretion after a liquid test meal: effects
of exogenous glucagon-like peptide-1 (GLP-1)-(7±36) amide in
Type 2 (non-insulin dependent) diabetic patients Journal of
Clinical Endocrinology and Metabolism, 81, 327±332.
Dandona P, Fonseca V, Mier A, Beckett AG (1983) Diarrhea and
metformin in a diabetic clinic Diabetes Care, 6, 472±474.
Day C (1999) Thiazolidinediones: a new class of antidiabetic drugs.
Diabetes Medicine, 16, 179±192.
DeFronzo RA, Goodman AM for the Multicenter Metformin Study
Group (1995) Ef®cacy of metformin in patients with non-insulin
diabetes mellitus New England Journal of Medicine, 333, 541±
549.
Diabetes Control and Complications Trial Research Group (1993) The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-depen- dent diabetes mellitus New England Journal of Medicine, 329, 977±986.
Drouin P Diamicron MR Study Group (2000) Diamicron MR once daily is effective and well tolerated in type 2 diabetes A double- blind, randomised, multinational study Journal of Diabetes Complications, 14, 185±191.
Drucker DJ, Philippe J, Mozsov S, Chick W, Habener JF (1987) Glucagon-like peptide I stimulates insulin gene expres- sion and increases cyclic AMP levels in a rat islet cell line Proceedings the National Academy of Sciences USA, 84, 3434± 3438.
Fineman MS, Giotta MP, Thompson RG, Kolterman OG, Koda JE (1996) Amylin response following Sustacal ingestion is dimin- ished in Type II diabetic patients treated with insulin Diabeto- logia, 39 (Suppl 1), A149 (abstract).
Frier B, Ashby JP, Nairn IM, Baird JD (1981) Plasma insulin, peptide and glucagon concentrations in patients with insulin- dependent diabetes treated with chlorpropamide Diabetes and Metabolism, 7, 45±49.
C-Fuhlendorff J (1998) Molecular identi®cation of speci®c binding site (36 kDa) for repaglinide Diabetes (Suppl 1), 496 (abstract) Garber AJ, Duncan TG, Goodman AM, Mills DJ, Rohlf JL (1997) Ef®cacy of metformin in Type II diabetes: results of a double- blind, placebo-controlled, dose response trial American Journal
of Medicine, 102, 491±497.
Gedulin BR, Rink TJ, Young AA (1997) Dose±response for glucagonostatic effect of amylin in rats Metabolism, 46, 67±70 Gerich JE (1989) Oral hypoglycemic agents New England Journal
of Medicine, 321, 1231±1245.
GoÈke R, Wagner B, Fehmann HC, GoÈke B (1993) dependency of the insulin stimulatory effect of glucagon-like peptide-1 (7±36) amide on the rat pancreas Research in Experimental Medicine, 193, 97±103.
Glucose-Gomis R, Jones NP, Vallance SE, Ratwardhan R (1999) Low dose rosiglitazone provides additional glycemic control when combined with sulfonylureas in Type 2 diabetes Diabetes, 48 (Suppl 1), Poster 266 A63.
Groop L (1992) Sulfonylureas in NIDDM Diabetes Care, 19, 737± 754.
Groop L, Perlkonen R, Koskimies S, Bottazzo GF, Doniach D (1986) Secondary failure to treatment with oral antidiabetic agents in non-insulin dependent diabetes Diabetes Care, 9, 129±133.
Groop L, Luzi L, Melander A, Groop PH, Ratheiser K, Simonson
DC, Defronzo RA (1987) Different effects of glyburide and glipizide on insulin secretion and hepatic glucose production in normal and NIDDM subjects Diabetes, 36, 1320±1328 Groop L, Groop PH, Stenman S, Saloranta C, ToÈtterman KJ,Fyhr- quist F, Melander A (1988) Do sulfonylureas in¯uence hepatic insulin clearance? Diabetes Care, 11, 689±690.
Groop L, Shalin C, Fonssila-Kallunki A, Widen E, Ekstrand A, Eriksson J (1989) Characteristics of non-insulin dependent diabetic patients with secondary failure to oral antidiabetic therapy American Journal of Medicine, 87, 183±190 Grosskopf I, Ringel Y, Charach G, Mahurshak N, Mor R, Iaina A, Weintraub M (1997) Metformin enhances clearance of chylo- microns and chylomicron remnants in nondiabetic mildly over- weight glucose-intolerant subjects Diabetes Care, 20, 1598± 1602.
Trang 2Grunberger G, Weston W, Patwardha R, Rappaport EB (1999)
Rosiglitazone once or twice daily improves glycemic control
in patients with Type 2 diabetes Diabetes, 48 (Suppl 1), Poster
439 A102.
Gutniak M, Larsson H, Sanders S, Juneskans O, Holst JJ, AhreÂn B
(1997) GLP-1 tablet in Type 2 diabetes in fasting and
post-prandial conditions Diabetes Care, 20, 1874±1879.
Hatorp V, Haug-Pihale G (1998) A comparison of the
pharmacoki-netics of repaglinide in healthy subjects with that in subjects
with chronic liver disease Diabetes (Suppl 1), 496 (abstract).
Hatorp V, Perentesis G, Nielsen K, WuF (1997) Pharmacokinetics
of repaglinide: a comparison between young and elderly healthy
subjects and elderly NIDDM patients Journal of Clinical
Pharmacology, 37, 874 (abstract).
Heinemann L, Richter B (1993) Clinical pharamacology of human
insulin Diabetes Care, 16 (Suppl 3), 90±100.
Heinemann L, Sinha K, Weyer C, Loftager M, Hirschbergert S,
Heise (1999) Time-action pro®le of the soluble, fatty acid
acylated, long-acting insulin analogue NN304 Diabetic
Medi-cine, 16, 332±338.
Hillebrand I (1987) Pharmacological modi®cation of digestion and
absorption Diabetic Medicine, 4, 147±150.
Hirschberg Y, McLeod J, Gareffa S, Spratt D (1999)
Pharmacody-namics and dose response of nateglinide in Type 2 diabetes.
Diabetes, 48 (Suppl 1), A100 (abstract).
Hollerman F, Hoekstra JB (1997) Insulin Lispro New England
Journal of Medicine, 337, 176±183.
Holman RR, Cull CA, Turner RC (1999) A randomized
double-blind trial of acarbose in Type 2 diabetes shows improved
glycemic control over 3 years (UK Prospective Diabetes
Study 44) Diabetes Care, 22, 960±964.
Holst JJ (1994) Glucagon-like peptide-1 (GLP-1): a newly
discov-ered GI hormone Gastroenterology, 107, 1848±1855.
Hume PD, Lindholm A, Hylleberg B, Round P (1998) Improved
glycemic control with insulin aspart: a multicenter, randomized,
double-blind crossover trial in Type 1 diabetic patients UK
Insulin Aspart Study Group Diabetes Care, 21, 1904±1909.
Inoue K, Hisatomi A, Umeda F, Nawata H (1991) Release of amylin
from perfused rat pancreas in response to glucose, arginine,
gamma-hydroxybutyrate, and gliclazide Diabetes, 40, 1005±
1009.
Iwamoto Y, Kosaka K, Kuzuya T, Akanuma Y, Shigeta Y, Kaneko T
(1996) Effects of troglitazone: a new hypoglycemic agent in
patients with NIDDM poorly controlled by diet therapy.
Diabetes Care, 19, 151±156.
Jennings AM, Wilson RM, Ward JD (1989) Symptomatic
hypogly-cemia in NIDDM patients treated with oral hypoglycemic
agents Diabetes Care, 12, 203±208.
Johnston PS, Lebovitz HE, Coniff R (1997) Advantages of
mono-therapy with alpha-glucosidase inhibitors in elderly NIDDM
patients Diabetes, 46 (Suppl 1), 158A (abstract).
Johnston PS, Lebovitz HE, Coniff RF, Simonson DC, Raskin P,
Munera CL (1998) Advantages of alpha glucosidase inhibition
as monotherapy in elderly Type 2 diabetic patients Journal of
Clinical Endocrinology and Metabolism, 83, 1515±1522.
Kahn CR, Schecte Y (1993) Oral hypoglycemic agents In: Gilman
AG, Rall TW, Nies AS, Taylor P (eds), The Pharmacologic
Basis of Therapeutics New York: McGraw-Hill, 1485.
Kalbag J, Hirschberg Y, McLeod JF, Gareffa S, Lasseter K (1999)
Comparison of mealtime glucose regulation of nateglinide and
repaglinide in healthy subjects Diabetes, 48 (Suppl 1), A206
(abstract).
Keller U, Muller R, Berger W (1986) Sulfonylurea therapy fails to diminish insulin resistance in Type 1 diabetic subjects Hormone and Metabolic Research, 18, 599±603.
Koda JE, Fineman M, Rink TJ, Daily GE, Muchmore DB, Linarelli
LG (1992) Amylin concentrations and glucose control Lancet,
339, 1179±1180.
Kolterman OG, Gottlieb A, Moyses C, Colburn W (1995) tion of post-prandial hyperglycaemia in subjects with IDDM by intravenous infusion of AC137, a human amylin analogue Diabetes Care, 18, 1179±1192.
Reduc-Kolterman OG, Olefsky JM (1984) The impact of sulfonylurea treatment upon the mechanisms responsible for the insulin resistance in Type II diabetes Diabetes Care, 7 (Suppl 1), 81±88.
Lepore M, Kurzhals R, Pampanelli S, Fanelli CG, Bolli GB (1999) Pharmacokinetics and dynamics of s.c injection of the long- acting insulin glargin (HOE 1) in T1DM Diabetes, 48 (Suppl 1), A97 (abstract).
Linkeschowa R, Heise T, Rave K, Hompesch B, Sedlack M, Heinemann L (1999) Time-action pro®le of the long acting insulin analogue HOE 901 Diabetes, 48 (Suppl 1), A97 (abstract).
Ludvik B, Lell B, Hartter E, Schnack C, Prager R (1991) Decrease
of stimulated amylin release precedes impairment of insulin secretion in Type II diabetes Diabetes, 40, 1615±1619 Maggs DG, Buchanan TA, Burant CF, Cline G, Gumbiner B, Hsueh
WA, Inzucchi S, Kelley D, Nolan J, Olefsky JM, Polonsky KS, Silver D, Valiquett TR, Shulman GI (1998) Metabolic effects of troglitazone monotherapy in Type 2 diabetes mellitus: a rando- mized double blind placebo controlled trial Annals of Internal Medicine, 128, 176±185.
Malaisse WJ (1995) Stimulation of insulin release by lurea hypoglycemic agents: the meglitinide family Hormone and Metabolic Research, 27, 263±266.
non-sulfony-Marbury T, Hatorp V (1998) Pharmacokinetics of repaglinide after single and multiple doses in patients with renal impairment compared with normal healthy volunteers Diabetes, 47 (Suppl 1), 496.
Marbury T, Strange (1998) Multicenter, randomized comparison of the therapeutic effects of long-term use of repaglinide with glyburide in Type 2 diabetes Diabetes 47 (Suppl 1), 496 (abstract).
Mathisen A, Geerlof J, Houser V (1999) Pioglitazone 026 Study Group The effect of pioglitazone on glucose control and lipid pro®le in patients with Type 2 diabetes Diabetes, 49 (Suppl 1), A441 (abstract).
Melander A, BitzeÂn PO, Faber O, Groop L (1989) Sulphonylurea antidiabetic drugs: an update of their clinical pharmacology and rational therapeutic use Drugs, 37, 58±72.
Mooradian AD (1987) The effect of sulfonylureas on the in vivo tissue uptake of glucose in normal rats Diabetologia, 30, 120± 121.
Mooradian AD (1996) Drug therapy of non-insulin-dependent diabetes mellitus in the elderly Drugs, 6, 931±941.
Mooradian AD (1998) Repaglinide: a viewpoint Drugs and Aging, 13(2), 181.
Mooradian AD, Neumann C (1997) Precose resolution of optimal titration to enhance current therapies (PROTECT) study: experi- ence in the elderly Annual Meeting of the American Geriatric Society, 153.
Mooradian AD, Thurman J (1999) Drug therapy of postprandial hyperglycemia Drugs, 97, 19±29.
Trang 3Mooradian AD, Osterweil D, Petrasek D, Morley JE (1988) Diabetes
mellitus in elderly nursing home patients: a survey of clinical
characteristics and management Journal of the American
Geria-trics Society, 36, 391±396.
Mooradian AD, Kalis J, Nugent CA (1990) The nutritional status of
ambulatory elderly Type II diabetic patients Age, 13, 87±89.
Mooradian AD, Albert SG, Wittry S, Chehade JM, Kim J,
Bellri-chard BA (2000) Dose-response pro®le of acarbose in older
subjects with Type 2 diabetes American Journal of Medical
Sciences (in press).
Morley JE, Mooradian AD, Rosenthal MJ, Kaiser FE (1987)
Diabetes mellitus in elderly patients: is it different? American
Journal of Medicine, 83, 533±544.
Moses R, Slobodniuk R, Donnelly T (1997) Additional treatment
with repaglinide provides signi®cant improvement in glycemic
control in NIDDM patients poorly controled on metformin.
Diabetes, 46 (Suppl 1), 93 (abstract).
Novo Nordisk (1997) Prandin 1 (repaglinide) Prescribing
informa-tion Novo Nordisk Pharmaceuticals, Princeton, NJ, USA.
Ogawa A, Harris V, McCorkle SK, Unger RH, Luskey KL (1990)
Amylin secretion from the rat pancreas and its selective loss
after streptozotocin treatment Journal of Clinical
Investiga-tions, 85, 973±976.
érskov C (1992) Glucagon-like peptide-1, a new homrone of the
enteroinsular axis Diabetologia, 35, 701±711.
Parke±Davis (1997) Rezulin (troglitazone) tablets Prescribing
information Morris Plains, New Jersey, USA.
Pearson JG, Antal EJ, Raehl CL, Gorsch HK, Craig WA, Albert KS,
Welling PG (1986) Pharmacokinetic disposition of 14 C
-glybur-ide in patients with varying renal function Clinical
Pharmacol-ogy and Therapeutics, 39, 318±324.
Perriello G, Misericordia P, Volpi E, Santucci C, Ferrannini E,
Ventura MM, Santeusanio F, Brunetti P, Bolli GB (1994)
Metformin in NIDDM: evidence for suppression of lipid
oxida-tion and hepatic glucose producoxida-tion Diabetes, 43, 920±928.
Pfeiffer MA, Beard JC, Halter JB, Judzewitsch R, Best JD, Porte D
Jr (1983) Suppression of glucagon secretion during a
tolbuta-mide infusion in normal and noninsulin-dependent diabetic
subjects Journal of Clinical Endocrinology Metabolism, 56,
586±591.
Pharmacia and Upjohn 1998 Glyset 1 (miglitol) Prescribing
infor-mation Pharmacia and Upjohn Company, Kalamazoo, MI, USA.
Pioglitazone 001 Study Group (1999) Pioglitazone: its effect in the
treatment of patients with Type 2 diabetes Diabetes, 48 (Suppl.
1), 469 (abstract).
Pittner RA, Albrandt K, Beaumont K, Gaeta LS, Koda JE, Moore
CX, Rittenhouse J, Rink TJ (1994) Molecular physiology of
amylin Journal of Cell Biochemistry, 55S, 19±28.
Plosker LG, Faulds D (1999) Troglitazone: a review of its use in the
management of Type 2 diabetes mellitus Drugs, 57, 409±438.
Rabasa-Lhoret R, Chiaisson JL (1998) Potential of a-glucosidase
inhibitors in elderly patients with diabetes mellitus and impaired
glucose tolerance Drugs and Aging, 13, 131±143.
Ratner R, Levetan C, Schoenfeld S, Organ K, Kolterman O (1998)
Pramlintide therapy in the treatment of insulin-requiring Type 2
diabetes: results of a 1-year placebo-controlled trial Diabetes,
47 (Suppl 1), A88 (abstract).
Ratzmann KP, Shulz B, Heinke P, Besch W (1984) Tolbutamide
does not alter insulin requirement in Type 1 (insulin-dependent)
diabetes Diabetologia, 27, 8±12.
Reed RL, Mooradian AD (1990) Nutritional status and dietary management of elderly diabetic patients Clinics in Geriatric Medicine, 6, 883±901.
Rink TJ, Beaumont K, Koda J, Young A (1993) Structure and biology of amylin Trends in Pharmacological Science, 14, 113± 118.
Roach P, Yuel L, Arora V (1999) The Humalog mix 25, a novel protamine-based insulin Lispro formulation Diabetes Care, 22, 1258±1261.
Rosenkranz B, Profozic V, Metelko Z, Mrzljak V, Lange C, Malerczyk V (1996) Pharmacokinetics and safety of glimepiride
at clinically effect doses in diabetic patients with renal ment Diabetologia, 39, 1617±1624.
impair-Rosenstock J, Samols E, Muchmore DB, Schneider J (1996) The Glimepiride Study Group Glimepiride, a new once-daily sulfo- nylurea: a double-blind, placebo-controlled study of NIDDM patients Diabetes Care, 19, 1194±1199.
Rosenstock J, Whitehouse F, Schoenfeld S, Dean E, Blonde L, Kolterman O (1998) Effect of pramlintide on metabolic control and safety pro®le in people with Type 1 diabetes Diabetes, 47 (Suppl 1), A88 (abstract).
Rosenthal MJ, Morley JE (1992) Diabetes and its complications in older people In: Morley JE and Korenman SG (eds), Endocri- nology and Metabolismin the Elderly Boston: Blackwell Scienti®c Publications, 373±387.
Rosskamp RH, Park G (1999) Long-acting insulin analogs Diabetes Care, 22 (Suppl 2), B109±B113.
Rubin C, Egan J, Schneider R for the Pioglitazone 014 Study Group (1999) Combination therapy with pioglitazone and insulin in patients with Type 2 diabetes Diabetes, 48 (Suppl 1), 473 (abstract).
Rybka J, Goke B, Sissmann J (1999) European comparative study of
2 alpha-glucosidase inhibitors, Miglitol and acarbose Diabetes,
48 (Suppl 1), 433A (abstract).
Santeusanio F, Compagnucci P (1994) A risk-bene®t appraisal of acarbose in the managment of non-insulin-dependent diabetes mellitus Drug Safety, 11, 432±444.
Scheen AJ (1997) Drug treatment on non-insulin-dependent diabetes mellitus in the 1990s: achievements and future devel- opments Drugs, 54, 355±368.
Schmitz O, Nyholm B, Orskov L, Gravholt C, Moller N (1992) Effects of amylin and the amylin agonist pramlintide on glucose metabolism Diabetic Medicine, 14 (Suppl 2), S19±S23 Schnieder R, Egan J, Houser V for the Pioglitazone 101 Study Group (1999) Combination therapy with pioglitzzone and sulfo- nylurea in patients with Type 2 diabetes Diabetes, 48 (Suppl 1),
SmithKline Beecham (1999) Avandia (Rosiglitazone) tablets Prescribing information Philadelphia, Pennsylvania, USA.
Trang 4Stang M, Wysowski DK, Butler Jones D (1999) Incidence of lactic
acidosis in metformin users Diabetes Care, 22, 925±927.
Stumvoll M, Nurijhan N, Perriello G, Dailey G, Gerich JE (1995)
Metabolic effects of metformin in non-insulin-dependent
diabetes mellitus New England Journal of Medicine, 333,
550±554.
Thompson RG, Gottlieb A, Organ K, Koda J, Kisicki G, Kolterman
OG (1997) Pramlintide: a human amylin analogue reduced
postprandial plasma glucose, insulin, and C-peptide
concentra-tions in patients with Type 2 diabetes Diabetic Medicine, 14,
547±555.
Thompson RG, Pearson L, Shoenfeld S, Kolterman OG for the
Pramlintide in Type 2 Diabetes Group (1998) Pramlintide, a
synthetic analog of human amylin, improves the metabolic
pro®le of patients with Type 2 diabetes using insulin Diabetes
Care, 21, 987±993.
Tomkin G (1973) Malabsorption of vitamin B 12 in diabetic patients
treated with phenformin: a comparison with metformin British
Medical Journal, 3, 673±675.
Torlone E, Fanelli C, Rambotti AM, Kassi G, Modarethi F, Di
Vincenzo A, Epifano L, Ciofetta M, Pampanelli S, Brunetti P
(1994) Pharmacokinetics, pharmacodynamics and glucose
coun-terregulation following subcutaneous injection of the
mono-meric insulin analogue [Lys(B28), Pro(B29)] in IDDM.
Diabetologia, 37, 713±720.
Tornier B, Marbury TC, Dambso P, Wind®eld K (1995) A new oral hypoglycemic agent, repaglinide, minimizes risk of hypoglyce- mia in well controlled Type 2 diabetic patients Diabetes, 44 (Suppl 1), 70A (abstract).
UK Prospective Diabetes Study Group (1995) Overview of 6 years' therapy of Type II diabetes: a progressive disease Diabetes, 44, 1249±1258.
UK Prospective Diabetes Study Group (1998a) Intensive glucose control with sulfonylureas or insulin compared with conventional treatment and risk of complications in patients with Type 2 diabetes (UKPDS 33) Lancet, 352, 837±853.
blood-UK Prospective Diabetes Study Group (1998b) Effect of intensive blood-glucose control with metformin on complications in over- weight patients with Type 2 diabetes (UKPDS 34) Lancet, 352, 854±865.
Williams RH, Palmer JP (1975) Farewell to phenformin for treating diabetes mellitus Annals of Internal Medicine, 83, 567±568.
WuMS, Johnston P, SheuWHH, Hollenbeck CB, Jeng CY,
Gold-®ne ID, Chen YD, Reaven GM (1990) Effects of metformin in NIDDM patients Diabetes Care, 13, 1±8.
Yki-Jarvinen H, Ryysy L, NikkilaÈ K, Tulokas T, Vanamo R, Heikkila M (1999) Comparison of bedtime insulin regimens in patients with Type 2 diabetes mellitus: a randomized controlled trial Annals of Internal Medicine, 130, 389±396.
Trang 5Rehabilitation
Paul Finucane, Maria Crotty
Flinders University, Adelaide
INTRODUCTIONEarlier chapters of this book have documented the
catastrophic events that can complicate the course of
diabetes mellitus For anybody, the onset of a stroke, a
myocardial infarct, an ischaemic limb requiring
am-putation, or signi®cant loss of vision is potentially
devastating The process of rehabilitation aims to
minimize the consequences of such catastrophes For
people young or old, diabetic or otherwise, the
prin-ciples of rehabilitation are broadly similar However,
special considerations arise when the patient happens
to be elderly and diabetic, as problems tend to be
complex and more dif®cult to address
An understanding of the terms `impairment',
`dis-ability' and `handicap' greatly facilitates an
apprecia-tion of the process of rehabilitaapprecia-tion Impairment refers
to a defect in an organ, a pathological process
Dis-ability refers to the loss of function resulting from the
impairment, and handicap to the social disadvantage
resulting from the disability Take, for example, a
woman with a thrombotic stroke resulting in
hemi-plegia The impairment is the cerebral infarct, indirect
evidence of which is found by neurological
examina-tion and more direct evidence by computerized
to-mography or magnetic resonance imaging scanning
Resulting disability may take the form of inability to
perform activities of daily living because of a motor
de®cit, hemianopia and sensory inattention
Conse-quently, she or he may be handicapped, and unable to
continue with former pastimes
Every impairment has the potential to trigger the
onset of disability and handicap While many
de®ni-tions of rehabilitation have been advanced, it can
simply be regarded as a process that minimizes the
disability and handicap resulting from impairment To
understand this process, it is essential to have an
un-derstanding of the determinants of disability andhandicap
FACTORS INFLUENCING THEDEVELOPMENT OF DISABILITY AND
HANDICAP
It is remarkable how people with similar underlyingimpairments differ in the extent of their resulting dis-ability and handicap For example, some people arefully independent and have resumed a normal life-stylewithin a few weeks of having an ischaemic leg am-putated, while others are left permanently in-capacitated, following months in hospital Some of themajor determinants of disability and handicap (sum-marized in Table 16.1) need to be recognized In anindividual patient, all these factors interact, and theyshould not therefore be considered as discrete
The Impairment
It is a truism that the greater the severity of an pairment, the greater the likelihood of disability andhandicap The site of the impairment may also beimportant For instance a small cerebral infarct invol-ving the internal capsule may cause profound dis-ability, while a much larger lesion involving a `silent'region of the brain may go unnoticed Some impair-ments may resolve spontaneously, be halted or be re-versed by therapeutic intervention, while othersinexorably progress The chronicity of the impairmentmay also be important For some people, long-standingimpairment promotes familiarity and the development
im-of adaptive skills, which limit disability Thus thediabetic person with angina learns to avoid exerciselikely to precipitate chest pain and=or use nitrate pro-
Diabetes in Old Age Second Edition Edited by A J Sinclair and P Finucane # 2001 John Wiley & Sons Ltd.
Copyright # 2001 John Wiley & Sons Ltd ISBNs: 0-471-49010-5 (Hardback); 0-470-84232-6 (Electronic)
Trang 6phylaxis In other situations, people become gradually
worn down by continuing impairment, consequently
fail to develop or lose adaptive skills, and so become
disabled and handicapped
Intrinsic Patient Factors
People with long-standing diabetes, irrespective of
their chronological age, may well have a number of
active impairments at any one time Thus, retinopathy
and nephropathy commonly coexist, and
macro-vascular disease may involve the coronary, cerebral
and peripheral vasculature simultaneously
Further-more, elderly patients, diabetic or otherwise, often
have coincidental diseases that are not necessarily
linked aetiologically For example, a person with
chronic chest disease may also have an arthropathy and
prostatic hyperplasia
The elderly diabetic patient tends to have the worst
of both worlds, with multiple impairments both related
and unrelated to diabetes Thus, visual impairment
may be as much a consequence of macular
degenera-tion as diabetic retinopathy and autonomic neuropathy
as much a consequence of Parkinson's disease as
dia-betes The presence of multiple impairments is of
particular importance in a rehabilitation setting where
it can prevent the achievement of goals Take, for
ex-ample, the patient recovering from a lower limb putation, whose angina and=or chronic chest diseaselimit exercise tolerance, or whose mobility is limited
am-by osteoarthritis and=or peripheral neuropathy ving the remaining leg
invol-The physical status of the patient prior to the onset
of the impairment therefore has a major impact on theextent of subsequent disability and handicap Otherthings being equal, the person who was ®t and activeprior to the onset of the impairment has a betterprognosis than another with pre-existing disease Un-fortunately, the lifestyles of many old people do notpromote cardiorespiratory or neuromuscular ®tness In
a Canadian study, for example, less than half of peoplewith Type 2 diabetes participated in any form of ex-ercise program, either formal or informal (Searle andReady 1991)
A decline in cardiorespiratory and neuromuscularfunction with aging means that an older person withimpairment is more likely to develop disability andhandicap than is a younger person with similar im-pairment (Seymour 1989) In the past, this lack of
`physiological reserve' to meet the challenge of a newimpairment has tended to receive undue emphasis,leading to nihilistic and agist attitudes in the area ofrehabilitation as elsewhere In practice, advancedchronological age per se is no barrier to successfulrehabilitation
As will be discussed later (see `Psychological pects of rehabilitation'), psychological factors have anenormous impact on the extent of disability and han-dicap resulting from impairment Thus the person whorapidly comes to terms with an impairment, perceives
as-it as a challenge rather than as a negative event and iswell motivated, is likely to fare better than another with
a different attitude
Extrinsic Patient FactorsAccess to high-quality healthcare can do much toprevent impairment in the elderly diabetic patient.Even if impairment develops, medical intervention canretard the progression to disability and handicap Forexample, vascular reconstructive surgery can reverselimb ischaemia and laser photocoagulation can retardthe development of visual loss in diabetic retinopathy
As will be explained, even when disability and dicap have resulted, a multidisciplinary rehabilitationteam can work to restore function and social compe-tence
han-Table 16.1 Factors in¯uencing the extent of disability and
Trang 7Reduced social supports are a particular problem for
the elderly diabetic patient In the UK, for example,
over 50 per cent of women and 25 per cent of men aged
over 65 years have no living spouse (Hine 1989) As a
result, one-third of this age group and an even greater
proportion of older groups live alone The vast
ma-jority of such people live full and independent lives,
even if they happen to be diabetic However, for those
who struggle to cope with illness, the physical and
emotional support that a partner, family members or
friends can provide is a major asset in preventing
disability and handicap The important role that pets
play in the lives of some people should also be
re-cognized
Financial resources or their lack can further
de-termine the extent to which impairment results in
disability and handicap Access to personal care and to
appropriate housing and technology can be expensive
and in all societies is in¯uenced to some extent by ones
ability to pay Here again, elderly people are
dis-advantaged In Australia, for example, 78 per cent of
older people are reliant on an age pension the
equivalent of 25 per cent of the average adult working
wage, and 85 per cent of pensioners are eligible for
means-tested supplementary bene®ts (Australian
In-stitute of Health, 1990)
CONDITIONS COMMONLY
NECESSITATING REHABILITATION
The chronic complications of diabetes (Table 16.2)
have been described in earlier chapters All of these
impairments can result in signi®cant disability andhandicap At a glance, it can be seen that some im-pairments can result in a number of disabilities, andthat some disabilities can be due to a number of dif-ferent impairments Before discussing speci®c re-habilitation issues, some general points aboutrehabilitation should ®rst be understood
REHABILITATION:
SOME GENERAL POINTSThe ProcessThe principles of rehabilitation are broadly similar,irrespective of the problem with which one is dealing
An understanding of impairment, disability and dicap as previously discussed, helps to explain theprocess, and the need for a multidisciplinary teamapproach A properly resourced rehabilitation teamwill have input from medical and nursing staff, phy-siotherapists, occupational therapists, speech patholo-gists, clinical psychologists and social workers.Diabetic patients in particular bene®t from access todietitians, orthotists and podiatrists
han-All rehabilitation programs must be planned The
®rst step is to accurately assess the patient's currentlevel of impairment, disability and handicap Diag-nostic skills and the appropriate use of investigativetechnology are required to de®ne the impairment Aplethora of assessment scales are available to assessdisability; the Barthel scale (Mahoney and Barthel1965) is most widely used and, despite its limitations,has stood the test of time While several `quality oflife' scales have been devised, the extent of handicaphas proved dif®cult to quantify owing to its subjectivenature It is also important to formally assess cognitivefunction, even in patients who appear alert and or-ientated At the very least this will establish a baseline,which may later prove useful The 30-point MiniMental Status Examination (Folstein, Folstein andMcHugh 1975) has become popular, perhaps because
it best combines sensitivity with ease of tion
administra-Following assessment, the next step is to identifygoals and a time frame within which to achieve them.All team members must be involved in these initialsteps, and it is essential that consensus be achieved,otherwise cohesion gives way to chaos The patient is
an important (though often forgotten) member of theteam It is crucial that he or she be involved in estab-
Table 16.2 Common impairments and resulting disabilities in
people with Type 2 diabetes
Neuropathy
Peripheral Impaired mobility
Impaired manual dexterity Autonomic Impaired mobility
Incontinence Impotence Retinopathy Visual impairment, blindness
Nephropathy Reduced exercise tolerance
Coronary artery disease Reduced exercise tolerance
Cerebrovascular disease Communication problems
Impaired cognition Visual problems Impaired mobility Incontinence Peripheral vascular disease Impaired mobility
Trang 8lishing goals, as any goal that is not shared by the
patient is unlikely to be achieved For goals to be
realistic, the patient's level of function prior to the new
impairment must be taken into account As a general
rule, it is unrealistic to aim for greater than the
pre-morbid level of function, though there may be
excep-tions to this
Having established goals, the combined talents of
the team are brought to bear in meeting them A
de-tailed description of the skills used by individual team
members when dealing with various impairments and
disabilities is beyond the scope of this chapter and is
well dealt with elsewhere (Andrews 1987) Medical
staff are mainly responsible for the identi®cation and
management of impairment In a rehabilitation setting,
they must focus on the current impairment,
coin-cidental impairments, underlying risk factors and
po-tential complications Thus in a diabetic patient who
has had a limb amputation, they may be called upon to
supervise the wound, treat phantom limb pain, monitor
diabetic control, and manage coexisting angina and
hypertension
Allied health staff are best equipped to manage
disability Occupational therapists primarily assess
problems encountered with activities of daily living
and help the patient to devise strategies to overcome
them Physiotherapists plan and implement physical
therapies that target speci®c problems, and enhance
cardiorespiratory and neuromuscular function Speech
pathologists have particular expertise in the area of
communication dif®culties and swallowing disorders
For some patients, the main disability may be
psy-chological rather than physical, and input from a
clinical psychologist can be invaluable in addressing
this Social workers have particular expertise in
help-ing patients to deal with handicap, the social
dis-advantage resulting from disability They can harness
the support needed to maintain a disabled person in the
community, as well as provide information, advice and
practical help with ®nancial and legal matters
While multidisciplinary team members have
dis-crete areas of expertise, it is essential that each also has
a global perspective which spans impairment,
dis-ability and handicap Each must understand what the
other is doing For example, the speech pathologist
must have knowledge of neuroanatomy and the
med-ical practitioner must understand the need for home
modi®cations and `meals on wheels' provision Nurses
are arguably the most holistic of the health professions,
as their role encompasses impairment, disability and
handicap In a hospital rehabilitation setting, they
en-sure continuity of patient care while other teammembers tend to be available only during `of®cehours' In this regard, they are the true linchpins of therehabilitation process
For such a disparate group to function with sion, there must be effective communication Whenteam members are co-located in a speci®c area (e.g arehabilitation unit), exchange of information occursregularly and informally In addition, most teams haveregular formal meetings to review the process of in-dividual patients and revise the rehabilitation goals Aleader or chairperson is required to ensure that allperspectives are aired and that consensus is reached.Team meeting should also be used for dischargeplanning and to organize follow-up following dis-charge from the unit
cohe-When to Rehabilitate
To be most effective, rehabilitation should start as soon
as possible, so as to prevent further impairment andminimize the risk of disability This implies that theinitial impairment can be compounded if managedinappropriately Take, for example, the patient with a
¯accid hemiplegia and therefore at risk of shouldersubluxation Inappropriate handling, as might occurwhen helping the patient to move in bed or to transfer
to a chair, can result in serious and persistent shoulderdamage (Reding and McDowell 1987) Such a pro-blem is less likely to develop in a rehabilitation settingwhere staff are sensitized and trained in its prevention.Selection of appropriate patients for rehabilitation isimportant and can sometimes be dif®cult On the onehand it is unfair to subject a patient who will notbene®t to a demanding rehabilitation program and inthe process to raise false expectations This is alsowasteful of resources On the other hand, those whomay bene®t, even to a limited extent, should not bedenied access to rehabilitation In certain situations, it
is appropriate to set modest goals, such as helping ahemiplegic patient to regain sitting balance or an am-putee patient to become wheelchair independent Thequality of the person's life can be greatly improved ifsuch goals are achieved
Patients are most likely to bene®t from a habilitation program if they are able to actively parti-cipate and if they are well motivated For those who donot bene®t, there is usually an identi®able reason, such
re-as an overwhelming physical impairment, cognitiveimpairment, depression or a personality disorder A
Trang 9small minority of patients will simply lack the
moti-vation to combat their impairment As explained later,
strategies exist to help such people
Where to Rehabilitate
The nature and extent of the impairment largely
de-termine this With some conditions, such as an
un-complicated myocardial infarction, only a few days of
in-hospital treatment is required and an out-patient
rehabilitation program is most appropriate Other
im-pairments, such as major strokes and limb
amputa-tions, generally require hospital-based rehabilitation,
at least in the early stages In large centres of
popula-tion, rehabilitation of elderly diabetic patients is often
carried out in units specializing in speci®c
impair-ments This has the advantage of allowing high levels
of expertise to be developed together with
com-plementary facilities such as workshops for arti®cial
limbs and appliances Having people with similar
im-pairments in a single unit provides opportunities for
patient education, the training of health professionals
and for research Specialized units have a role in
set-ting standards of excellence and in the design,
im-plementation and evaluation of new therapeutic tools
and techniques However, the principles of
rehabilita-tion can be applied in any setting, provided that staff
with the necessary knowledge, skills and attitudes are
available
There is increasing evidence to support
rehabilita-tion in the home (Shepperd and Iliffe 1998)
Rando-mized trials have suggested that outcomes achieved by
offering home rehabilitation to patients with strokes
are comparable with those obtained in hospital These
programs do not appear to increase burden on carers
(Gunnell et al 2000) and are less expensive (Anderson
et al 2000) With the proliferation of geriatric day
hospitals in the 1960s, much rehabilitation is now
undertaken in an outpatient setting, often after an
in-itial period of more intensive in-patient treatment
Alternative community-based or domiciliary-based
rehabilitation programs are increasingly being
devel-oped and may have some advantages over traditional
day hospital programs (Young and Forster, 1992)
Psychological Aspects of Rehabilitation
The onset of impairment is usually associated with
some emotional disturbance, particularly if the event is
catastrophic (e.g a major stroke or loss of a limb)
There may be a feeling of loss with regard to onesphysical and=or mental faculties, to relationships withothers or to inanimate objects such as ones home orother possessions Normally, a grief reaction occurs,with phases of denial, anger and depression leading to
a level of acceptance suf®cient to allow a relativelynormal life to be resumed However, adjustment toimpairment is sometimes abnormal For example, 20%
of people have severe and often persistent depressionfollowing acute myocardial infarction (Leng 1994).Several studies have documented high levels of psy-chosocial dysfunction in people following a stroke(Ahlsio et al 1984; Schmidt et al 1986) even despiteparticipation in a rehabilitation program (Young andForster 1992)
The manner in which people adapt to impairmentgreatly in¯uences the development of disability andhandicap Some people seem to be inherently moreadaptable than others in responding positively to anadverse situation Such `highly motivated' people arekeen to participate in a rehabilitation program, andwork hard to achieve their goals At the other end ofthe spectrum are those who appear to succumb toimpairment, disengage, surrender power and auton-omy and adopt a `sick role'
There are psychological theories to explain suchdifferent responses Kemp (1988) has proposed anexcellent model, which explains motivation as a dy-namic process, determined by four elements: the per-son's wants; beliefs; the rewards for achievement; andthe costs to the patient Thus if a person really wantssomething, believes it to be attainable and if attainment
is likely to bring reward, they will strive to achieve it,provided the cost (in terms of pain and effort) is ac-ceptable On the other hand, a lack of achievement canoccur if the goal is not strongly wanted, if the personbelieves that it cannot be attained, if there is little or noreward for attaining the goal, or if the perceived cost ofachievement is too high By using this framework, therehabilitationist can help individual patients in anumber of ways
First, a patient can be helped to identify wants or, inother words, to establish goals In a rehabilitationsetting, failure to achieve goals is often attributable totheir being set by rehabilitationists without reference tothe patient The role of therapists is to ensure that thegoals which patients set themselves are realistic Ifgoals are unrealistic, the patient should be encouraged
to modify them Second, the patient's beliefs should beexplored and important misconceptions should becorrected Third, having established what goals are
Trang 10important to the patient, the rehabilitationist should
ensure that he or she is appropriately rewarded when
goals are achieved Interim goals as well as ®nal goals
should be set and rewarded For example, a patient
who has regained a certain level of independence
might have some weekend leave from hospital, the
time spent at home increasing as new goals are met
When progress is gradual, patients will need to be
reminded of their achievements It is often useful to
have concrete evidence of progress, as when a
hemi-plegic patient compares their current status with a
video of themselves taken shortly after the onset of
impairment Finally, the patient's perception of the cost
of rehabilitation needs to be explored, and any
mis-conceptions should be addressed
It follows that an understanding of individual
pa-tients is a prerequisite for successful rehabilitation
This can be achieved only by listening, not just to the
people concerned, but to others who know them
in-timately Health professionals should consistently
de-monstrate a positive approach to patients as well as to
their progress at rehabilitation Respecting patients as
people fosters a sense of self-worth and, among other
things, further enhances motivation While providing
positive feedback is important, honesty and sincerity
should never be compromised, and false expectations
should not be generated
By acting as a `self-help group' or `therapeutic
community', patients participating in a rehabilitation
program can provide each other with support and
couragement The rehabilitation team should
en-deavour to create an atmosphere conducive to this and
should structure the ward and organize ward activities
so as to promote camaraderie On the other hand,
re-lationships between patients are occasionally
destruc-tive and staff may need to intervene if the rehabilitation
program is to be salvaged For example, sleeping and
dining arrangements may need to be reviewed so that
some people are kept apart
It is worthwhile remembering that for many patients
with diabetes, concerns about the future may be just as
signi®cant as concerns about the present The onset of
one disability may trigger justi®able apprehension
about further loss in the future Thus, the onset of
angina pectoris may raise fears of a fatal myocardial
infarct and calf claudication may raise fears of limb
amputation Indeed anxieties about future morbidity
and premature mortality can be an important source of
`dis-ease' in people with `uncomplicated' diabetes
Again, listening to the patient is the key to identifying
and addressing the problem Unless concerns for the
future surface spontaneously, they should be sought bydirect questioning
All members of the multidisciplinary rehabilitationteam should at least have a basic understanding of thepsychology of loss and motivation and have somepractical skills to overcome those problems that com-monly surface More complex problems may requireinput from a clinical psychologist and having access tosuch expertise is most valuable Psychologists alsohave an educative role in helping other team members
to understand their own feelings and behaviour Theycan also help to resolve con¯ict, whether arising within
or between patients, within or between team members
or between patients and team members
SPECIFIC REHABILITATION PROBLEMSFor reasons stated earlier, rehabilitation problems sel-dom exist in isolation in the elderly diabetic patient.Thus, the person whose immediate concern is a lowerlimb amputation may also have a residual hemiparesisfrom a previous stroke, together with angina and visualimpairment Efforts to regain mobility can be in¯u-enced as much by the remote as the recent problems It
is therefore somewhat arti®cial to discuss speci®cproblems as if they existed in isolation In the clinicalsetting it is essential to have an holistic approach,particularly as attempts to relieve one problem mayexacerbate another Thus, attempts to mobilise a pa-tient who has had a limb amputation may provoke anacute myocardial infarct, while drug therapy for anginamay exacerbate peripheral vascular disease, heartfailure or renal failure These considerations should bekept in mind when considering speci®c rehabilitationproblems
The Patient With StrokeFor the person with diabetes, a stroke is undoubtedlythe impairment with the greatest potential to causedisability and handicap About 20% of those havingtheir ®rst stroke are dead within a month, and one-third
of survivors have severe residual disability (Sacco et al1982) Motor and sensory de®cits, gait disorders,cognitive de®cits, visual ®eld defects, communicationdisorders, dysphagia and incontinence are all poten-tially devastating and all too common sequelae Somepatients will have a number of these disabilities Adetailed description of the rehabilitation process fol-lowing stroke is beyond the scope of this text Readers
Trang 11are referred to the admirably concise and informative
papers on the topic by Reding and McDowell (1987)
and Black-Schaffer, Kirsteins and Harvey (1999)
A few points are worthy of emphasis, however For
the individual, it is often dif®cult to predict outcome in
the immediate aftermath of a stroke and in the process
to decide on the utility or futility of a rehabilitation
program Epidemiological evidence indicates that
previous health status, the extent and severity of the
stroke, and the level of consciousness, cognition and
continence following the stroke are the best pointers
(Flicker 1989) However, most who survive the acute
stage improve to some extent Serial assessments
suggest that the great bulk of recovery occurs in the
®rst 6 months after stroke and most patients reach their
best `activities of daily living' (ADL) function within
13 weeks of stroke onset (Jorgensen et al 1995)
Having a range of rehabilitation options to choose
from is the ideal, with those most likely to improve
being admitted to the more intensive programs For
some people, rehabilitation goals must be modest
They are nonetheless valid, as helping people to
re-cover their ability to swallow, to transfer from bed to
chair more easily or to become
wheelchair-in-dependent can greatly enhance the quality of life The
role of the various members of the multidisciplinary
rehabilitation team is described elsewhere (Reding and
McDowell 1987) As with all rehabilitation situations,
the role that the patient's family has to play should not
be forgotten
At present there is much interest in early treatments
of stroke For example, thrombolysis offers the hope of
reducing the size of an ischaemic stroke and resultant
disability, albeit with an increased risk of intracerebral
bleeding (Wardlaw, Yamaguchi and Del Zoppo 1998)
However, at this stage the window of opportunity for
treatment is three hours following the onset of
symp-toms, and only a small proportion of patients present at
this early stage and are managed by services with the
potential to deliver treatments within this timeframe
Until larger trials convincingly demonstrate the
bene-®ts and identify the most appropriate patient groups,
timing and delivery strategies, most patients will need
to rely on rehabilitation to reduce their disability
fol-lowing stroke When provided by a specialist team,
stroke rehabilitation reduces mortality and morbidity
for stroke victims (Stroke Unit Trialists' Collaboration
1997) However, little is known about which
compo-nents are effective and the process is often therefore
referred to as a `black box' Factors assumed to be
important are: early mobilization, increased awareness
and treatment of medical complications, aggressivetreatment of risk factors (e.g hypertension and atrial
®brillation) and therapy Increasing interest is nowbeing shown in identifying those therapies whichwork, when they should be used and how frequently(Kwakkel et al 1999) Therapy directed at speci®ctasks appears more likely to produce better outcomes.For example, early treadmill training with partial bodysupport may produce better walking (Hesse et al 1995)and the more practice the better the result (Kwakkel et
al 1999) However, the relationship between the maged brain tissue and therapies is poorly understoodand the impact of various therapy approaches on neuralrecovery is only starting to be explored (Pomeroy andTallis 2000)
da-The Patient with Myocardial InfarctionNot only are diabetic patients more susceptible tomyocardial infarction, they are also at greater risk fromits consequences in both the short term and long term.For example, one-quarter of diabetic patients admitted
to hospital with acute infarction do not survive todischarge (Malmberg and Ryden 1988) Comparedwith non-diabetics, the overall mortality of diabeticsafter infarction is four times higher among men andseven times higher among women (Lundberg et al1997) Poor pre-infarction cardiac status and greaterdamage resulting from the infarct, together with thediabetic state itself, all seem to contribute to the rela-tively poor prognosis Fatal reinfarction is a particularconcern, being over twice as common in diabetic than
in non-diabetic people (Malmberg and Ryden 1988).Rehabilitation programs that aim to improve thelong-term prognosis for people after myocardial in-farction have been described and evaluated They tend
to be exercise-based, though some also aim to optimizesocial and psychological recovery and reduce oreliminate risk factors for coronary artery disease.Meta-analyses suggest a survival advantage of 20%(O'Connor et al 1989), and hospital-directed homeexercise programs provide similar functional results asgroup exercise programs (Miller et al 1984), althoughdepressed mood may be less common in those enrolled
in group programs (Taylor et al 1986) The bene®tswere apparent one year after randomization and per-sisted for at least three years Almost all studies haveexcluded elderly subjects and provide no data on thesub-group of subjects with diabetes There is therefore
no evidence of the ef®cacy of post-infarction
Trang 12rehabilitation programs for elderly diabetic patients.
However, because of the relatively poor prognosis of
myocardial infarction, this group has potentially the
most to gain At the very least, exercise programs
en-hance esteem, feelings of autonomy and
self-con®dence (Fentem 1994)
Before embarking on any exercise-based
re-habilitation program, it is important to establish that
exercise is safe and to quantify the level of
cardior-espiratory reserve An exercise stress test under the
supervision of a trained health professional clari®es
these issues Assessing functional reserve allows
ex-ercise programs to be tailored to the individual and
allows progress to be measured It is also important to
identify factors that limit the ability to exercise, as
some of these, for example foot deformities or
un-suitable footwear, can be recti®ed Aerobic exercise (in
which muscular effort is sustained by oxygen) and not
anaerobic exercise should be engaged in In practice,
exertion that leads to muscular aches and pains on the
following day should be avoided New guidelines from
the Australian National Institute of Health (1996)
re-commend the accumulation of 30 minutes of moderate
intensity physical activity over the course of most,
preferably all days of the week If the patient
experi-ences angina during or following exercise, this
regi-men must be revised
An alternative approach is a low-intensity group
approach such as that which is often used in Australian
cardiac rehabilitation programs This does not require
initial exercise testing for risk strati®cation or
mon-itoring Patients are taught to monitor their own
ex-ercise levels based on perceived exertion They are
advised to exert themselves to the level at which they
breathe more deeply but still talk comfortably while
exercising Low-intensity group programs achieve
si-milar improvements in quality of life and physical
®tness as high-intensity exercise programs (Worcester
et al 1993)
Assuming that medications (e.g beta-blockers)
which control heart rate are not being prescribed,
in-dividual patients should aim to maintain heart rate
within a predetermined range when exercising To this
end, the pulse rate should be monitored regularly, and
the degree of exercise modi®ed accordingly An
ade-quate warm-up and cool-down period should begin
and end every exercise session Running, swimming,
cycling, tennis and gym workouts are examples of
suitable exercise Exercise that the person ®nds
en-joyable is best Those struggling to psychologically
adjust to a recent myocardial infarction may ®nd it
helpful to meet with others who are similarly affected
Though a graded aerobic exercise program isusually prescribed following a myocardial infarction,there is increasing interest in the role of resistanceexercise programs particularly in the elderly cardiacpatient Resistance exercise programs (typically asingle set of 8±15 repetitions of 8±10 exercises, per-formed two to three times each week) have been em-phasized in older adults to reduce age-associatedreductions in muscle strength and subsequent dis-ability Evidence suggests that decreases in bloodpressure and heart rate can be achieved with suchprograms (Kelley and Kelley 2000) but controversysurrounds their use after acute myocardial infarction.While many programs include some strength training(Hare et al 1995), recent American Heart Advisoryguidelines found that there is insuf®cient researchevidence to support the routine prescription of re-sistance training for people with moderate to highcardiac risk (Pollock et al 2000)
The Amputee Patient
As peripheral vascular disease is now the main cause
of lower limb amputations in Western countries, themajority of amputee patients are elderly and many arediabetic In the UK, 80% of people undergoing lowerlimb amputation are aged over 60 years (Chadwick andWolfe 1992) In the United States, 45% of all patientsundergoing lower limb amputation in the late 1970swere diabetic (Most and Sinnock 1983) Furthermore,these authors reported that the incidence of lower limbamputation was some 15 times higher in diabetic than
in non-diabetic people Wide variation has been ported in the incidence of limb amputations, withEuropean rates being consistently lower than those inthe US (LEA Study Group 1995) For example, in
re-1991 the age-adjusted incidence of diabetes-relatedlower limb amputations was signi®cantly higher inCalifornia than in the Netherlands (49.9 comparedwith 36.1 per 10 000 diabetics), suggesting that access
to healthcare and healthcare funding models impact onthe incidence of amputations (Van Houtum and Lavery1996)
The process of rehabilitating the elderly diabeticamputee goes through a number of overlapping stages(Andrews 1996) Getting the stump to heal is the ®rststep, and an adequate blood supply is crucial Surgeonsaim to preserve as much of a limb as possible withoutcompromising the viability of the stump Whether theinitial procedure should be trans-tibial (or below-kneeamputationÐBKA) or trans-femoral (above-knee