CHAPTER ONE

INTRODUCTION
1.1. Background of the Study
2. Diabetes Mellitus (DM) represents a complex, chronic metabolic disorder characterized
by persistent hyperglycemia (elevated blood glucose levels) resulting from defects in
insulin secretion, insulin action, or both. This dysregulation disrupts the metabolism of
carbohydrates, fats, and proteins, leading to acute metabolic decompensation and long-
term damage, dysfunction, and failure of various organs, particularly the eyes, kidneys,
nerves, heart, and blood vessels (American Diabetes Association Professional Practice
Committee, 2024; International Diabetes Federation, 2021).
3. The global burden of diabetes is staggering and escalating. According to the International
Diabetes Federation (IDF) Diabetes Atlas (2021), approximately 537 million adults (20-
79 years) were living with diabetes worldwide in 2021. This number is projected to rise to
643 million by 2030 and 783 million by 2045. This increase is driven by complex
interactions of factors including aging populations, urbanization, sedentary lifestyles,
dietary shifts towards processed foods and sugary beverages, and rising obesity rates.
Diabetes imposes an immense health and economic burden, contributing significantly to
cardiovascular disease (the leading cause of death globally), kidney failure, blindness, and
lower limb amputations. The IDF estimated global diabetes-related health expenditures
reached USD 966 billion in 2021, representing a 316% increase over the past 15 years
(IDF, 2021).

3.1. Aim of the Study

The primary aim of this case study is to explore the diagnosis, management, and outcomes
for a 45-year-old woman with cataracts, with a focus on understanding the impact of cataracts
on her vision, daily activities, and overall quality of life.

1.3. Objectives of the Study

1. To assess the clinical presentation and severity of cataracts in the patient.
2. To evaluate the effectiveness of different treatment options for cataracts in mid-aged
adults.
3. To analyze the psychological and social impact of cataracts on the patient’s life.

1.4. Operational Definitions of Terms

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Type 2 Diabetes Mellitus (T2DM): A chronic metabolic disorder characterized by
hyperglycemia resulting from a combination of insulin resistance (where body tissues
respond poorly to insulin) and relative insulin deficiency (where pancreatic beta-cells fail to
secrete enough insulin to compensate), distinct from autoimmune Type 1 diabetes.
Hyperglycemia: A condition marked by abnormally high levels of glucose (sugar)
circulating in the blood plasma. In diabetes diagnosis/management, this is typically defined as
fasting plasma glucose ≥126 mg/dL (7.0 mmol/L), 2-hour plasma glucose during OGTT ≥200
mg/dL (11.1 mmol/L), HbA1c ≥6.5%, or random glucose ≥200 mg/dL with symptoms.
Hypoglycemia: A potentially dangerous condition occurring when blood glucose levels fall
below the normal range, typically defined as <70 mg/dL (3.9 mmol/L). In older adults, it is
particularly concerning due to increased risk of falls, cardiovascular events, and cognitive
impairment, often with attenuated autonomic warning symptoms.
Multimorbidity: The co-occurrence of two or more chronic medical conditions in the same
individual. In older adults with diabetes, common comorbidities include hypertension,
dyslipidemia, cardiovascular disease, chronic kidney disease, osteoarthritis, osteoporosis,
cognitive impairment, and depression, complicating management.
Frailty: A clinically recognizable state of increased vulnerability resulting from age-
associated declines in physiological reserve and function across multiple organ systems. It is
characterized by diminished strength, endurance, reduced physiological function, and
increased susceptibility to stressors, significantly impacting diabetes management goals and
prognosis.
Chronic Disease Management:* A coordinated approach to healthcare that involves long-
term monitoring, lifestyle modification, medication adherence, and regular check-ups for
diseases like diabetes.
Health Literacy: The ability of individuals to understand, interpret, and act upon health
information to make informed decisions and take control of their health.
Glycemic Control: The medical goal of maintaining blood sugar levels within a
recommended range to reduce the risk of diabetes complications and improve patient
outcomes.
Traditional Medicine: Indigenous healthcare practices and herbal remedies used in treating
illness, often based on cultural beliefs, and commonly employed in rural African settings.
Quality of Life: A multi-dimensional concept encompassing physical health, psychological
state, level of independence, social relationships, and personal beliefs, especially in chronic
illness contexts.
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.

CHAPTER TWO
2.0. LITERATURE REVIEW
The literature review for this case study will be reviewed under the following subheadings:
2.1. Overview of Diabetics Mellitus
2.1.1. Introduction: Defining the Global Epidemic
Diabetes Mellitus (DM) represents a complex, chronic metabolic disorder characterized by
persistent hyperglycemia (elevated blood glucose levels) resulting from defects in insulin
secretion, insulin action, or both. This dysregulation disrupts the metabolism of
carbohydrates, fats, and proteins, leading to acute metabolic decompensation and long-term
damage, dysfunction, and failure of various organs, particularly the eyes, kidneys, nerves,
heart, and blood vessels (American Diabetes Association Professional Practice Committee,
2024; International Diabetes Federation, 2021).
The global burden of diabetes is staggering and escalating. According to the International
Diabetes Federation (IDF) Diabetes Atlas (2021), approximately 537 million adults (20-79
years) were living with diabetes worldwide in 2021. This number is projected to rise to 643
million by 2030 and 783 million by 2045. This increase is driven by complex interactions of
factors including aging populations, urbanization, sedentary lifestyles, dietary shifts towards
processed foods and sugary beverages, and rising obesity rates. Diabetes imposes an immense
health and economic burden, contributing significantly to cardiovascular disease (the leading
cause of death globally), kidney failure, blindness, and lower limb amputations. The IDF
3
estimated global diabetes-related health expenditures reached USD 966 billion in 2021,
representing a 316% increase over the past 15 years (IDF, 2021).
2.1.2. Classification of Diabetes Mellitus
The classification of diabetes has evolved, moving away from terms like "insulin-dependent"
or "non-insulin-dependent" towards etiological categories. The most widely accepted
classifications are those from the American Diabetes Association (ADA) and the World
Health Organization (WHO), which largely align (American Diabetes Association
Professional Practice Committee, 2024; World Health Organization, 2019). The main
categories are:
1. Type 1 Diabetes Mellitus (T1DM): Caused by autoimmune β-cell destruction, usually
leading to absolute insulin deficiency.
2. Type 2 Diabetes Mellitus (T2DM): Caused by a progressive loss of β-cell insulin
secretion frequently on the background of insulin resistance.
3. Gestational Diabetes Mellitus (GDM): Diabetes diagnosed in the second or third
trimester of pregnancy that was not clearly overt diabetes prior to gestation.
4. Specific Types of Diabetes Due to Other Causes:
 Monogenic Diabetes Syndromes (e.g., MODY: Maturity-Onset Diabetes of the
Young, neonatal diabetes)
 Diseases of the Exocrine Pancreas (e.g., pancreatitis, pancreatectomy, cystic fibrosis)
 Endocrinopathies (e.g., Cushing's syndrome, acromegaly, pheochromocytoma)
 Drug- or Chemical-Induced Diabetes (e.g., glucocorticoids, antipsychotics, after
organ transplantation)
 Infections (e.g., congenital rubella, cytomegalovirus)
 Uncommon forms of immune-mediated diabetes (e.g., "Stiff-person" syndrome, anti-
insulin receptor antibodies)
 Other Genetic Syndromes Sometimes Associated with Diabetes (e.g., Down
syndrome, Klinefelter syndrome, Turner syndrome, Prader-Willi syndrome).
2.1.3. Pathophysiology: The Core of Hyperglycemia
Regardless of the type, the fundamental defect in diabetes is an inability to maintain
normoglycemia due to an imbalance between insulin availability and insulin need. Insulin,
secreted by pancreatic β-cells in the islets of Langerhans, is the primary anabolic hormone
regulating glucose homeostasis. Its key actions include:
Promoting Glucose Uptake: Stimulating glucose transport into skeletal muscle and adipose
tissue via GLUT4 translocation.
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Inhibiting Hepatic Glucose Production: Suppressing glycogenolysis (breakdown of
glycogen) and gluconeogenesis (production of new glucose) in the liver.
Promoting Glycogen Synthesis: Stimulating storage of glucose as glycogen in liver and
muscle.
Inhibiting Lipolysis: Reducing breakdown of fats in adipose tissue.
Promoting Protein Synthesis: Stimulating amino acid uptake and protein synthesis in
muscle.
Inhibiting Ketogenesis: Preventing excessive production of ketone bodies by the liver.
Hyperglycemia arises when insulin secretion is insufficient to overcome insulin resistance, or
when absolute insulin deficiency exists. Chronic hyperglycemia drives tissue damage through
several interconnected pathways:
Increased Polyol Pathway Flux: Excess glucose is metabolized via aldose reductase to
sorbitol, depleting NADPH and glutathione (key antioxidant), causing osmotic stress and
oxidative damage.
Advanced Glycation End-Product (AGE) Formation: Glucose non-enzymatically attaches
to proteins, lipids, and nucleic acids, forming AGEs. AGEs alter protein function, generate
reactive oxygen species (ROS) via receptor (RAGE) binding, and promote inflammation and
vascular damage.
Protein Kinase C (PKC) Activation: Hyperglycemia increases diacylglycerol (DAG)
synthesis, activating PKC isoforms. PKC activation contributes to vascular dysfunction,
altered gene expression, angiogenesis abnormalities, and increased permeability.
Increased Hexosamine Biosynthetic Pathway Flux: Excess fructose-6-phosphate is
diverted into this pathway, leading to O-linked glycosylation of transcription factors (like
Sp1), altering gene expression (e.g., increasing PAI-1 promoting thrombosis, decreasing
GLUT4 expression).
Mitochondrial Superoxide Overproduction: Hyperglycemia increases electron donors
(NADH, FADH2) to the electron transport chain, exceeding capacity and causing superoxide
(ROS) leakage. This mitochondrial ROS is considered a key initiator activating the other
pathways above (Brownlee, 2020).
2.1.4. Type 1 Diabetes Mellitus (T1DM)
Definition: T1DM is a chronic condition characterized by severe insulin deficiency resulting
from autoimmune-mediated destruction of pancreatic β-cells in genetically susceptible
individuals. Absolute insulin deficiency necessitates lifelong exogenous insulin therapy for
survival (American Diabetes Association Professional Practice Committee, 2024).
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Epidemiology: Accounts for approximately 5-10% of all diabetes cases. Incidence varies
geographically, being highest in Northern Europe. Incidence is increasing globally,
particularly in young children (Dimitri, 2020). There are peaks in incidence around ages 4-7
years and near puberty (10-14 years), but onset can occur at any age (termed Latent
Autoimmune Diabetes in Adults - LADA when onset is after ~30 years).
Environmental Triggers: Factors implicated in triggering autoimmunity in susceptible
individuals include viral infections (e.g., enteroviruses like Coxsackievirus B, rubella,
mumps), dietary factors (e.g., early exposure to cow's milk, gluten, vitamin D deficiency), gut
microbiome dysbiosis, and possibly toxins (Stene et al., 2020; Vangoitsenhoven & Cresci,
2020).
Stages of Development: The ADA now recognizes three distinct stages (American Diabetes
Association Professional Practice Committee, 2024):
Stage 1: Autoimmunity (≥2 islet autoantibodies present) with normoglycemia. No symptoms.
Stage 2: Autoimmunity with dysglycemia (e.g., impaired fasting glucose, impaired glucose
tolerance). No symptoms.
Stage 3: Clinical diagnosis with symptomatic hyperglycemia and/or diabetic ketoacidosis
(DKA).
2.1.5. Type 2 Diabetes Mellitus (T2DM)
Definition: T2DM is characterized by a combination of insulin resistance in peripheral
tissues (muscle, liver, adipose) and relative insulin deficiency due to β-cell dysfunction. It
represents the vast majority (90-95%) of diabetes cases worldwide (American Diabetes
Association Professional Practice Committee, 2024; International Diabetes Federation, 2021).
Epidemiology: Prevalence is rising dramatically, paralleling the global obesity epidemic.
Risk factors include obesity (especially central/visceral adiposity), physical inactivity, family
history, certain ethnicities (e.g., South Asian, African-Caribbean, Hispanic, Native
American), aging, history of GDM, and polycystic ovary syndrome (PCOS). Onset is
typically gradual and occurs later in life, although alarming increases in incidence are seen in
adolescents and young adults due to childhood obesity (Mayer-Davis et al., 2017).
Pathophysiology: A complex interplay of genetic predisposition and environmental/lifestyle
factors leading to insulin resistance and β-cell failure. Unlike T1DM, autoimmunity is not a
primary feature.
Genetic Susceptibility: T2DM has a strong heritable component, but it is polygenic,
involving hundreds of common variants, each conferring a small increase in risk. Genome-
wide association studies (GWAS) have identified numerous susceptibility loci, many
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involved in β-cell function (e.g., TCF7L2, KCNJ11, ABCC8, SLC30A8), insulin signaling
(e.g., IRS1, PPARG), and adipocyte biology (e.g., FTO). Epigenetic modifications induced
by factors like maternal hyperglycemia or early life nutrition also play a role (Mahajan et al.,
2022; Ali, 2019).
2.1.6. Gestational Diabetes Mellitus (GDM)
Definition: GDM is defined as diabetes diagnosed in the second or third trimester of
pregnancy that is not clearly overt diabetes prior to gestation (American Diabetes Association
Professional Practice Committee, 2024).
Epidemiology: Prevalence varies widely (1-28%) depending on diagnostic criteria, ethnicity,
and population risk factors (e.g., obesity, age, family history). Rates are rising globally due to
increasing maternal age and obesity (Ferrara, 2021).
Pathophysiology: Pregnancy is a state of progressive insulin resistance, primarily driven by
placental hormones (human placental lactogen - hPL, progesterone, cortisol, prolactin) and
increased maternal adiposity. These hormones antagonize insulin action, ensuring adequate
glucose supply to the fetus. Normally, maternal β-cells compensate by increasing insulin
secretion 2-3 fold. GDM develops when maternal β-cell function is insufficient to overcome
the insulin resistance of pregnancy (Plows et al., 2018).
2.1.7. Other Specific Types of Diabetes
i. Monogenic Diabetes (MODY and Neonatal Diabetes):
Definition: Caused by single-gene mutations, typically inherited in an autosomal dominant
manner. MODY usually presents in adolescence or young adulthood (<25 years), often with a
strong family history. Neonatal diabetes presents within the first 6 months of life (Hattersley
& Patel, 2022).
Pathophysiology: Mutations disrupt β-cell development or function. Common types include:
 GCK-MODY (MODY2): Glucokinase mutations (act as glucose sensor) cause mild,
stable fasting hyperglycemia present from birth. Minimal complications; rarely
requires treatment beyond diet.
 HNF1A-MODY (MODY3) & HNF4A-MODY (MODY1): Transcription factor
mutations cause progressive β-cell dysfunction. Sensitive to sulfonylureas.
 HNF1B-MODY (MODY5): Associated with renal cysts and uterine abnormalities.
 Neonatal Diabetes: Mutations in genes like KCNJ11 (Kir6.2 subunit of KATP
channel), ABCC8 (SUR1 subunit of KATP channel), INS (insulin gene). KATP
channel mutations often respond dramatically to sulfonylureas (Pearson, 2019).
ii. Diseases of the Exocrine Pancreas (Pancreatogenic or Type 3c Diabetes):
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Definition: Diabetes resulting from damage to the pancreas from conditions like chronic
pancreatitis, pancreatic cancer, cystic fibrosis (CFRD), hemochromatosis, pancreatectomy,
trauma, or fibrocalculous pancreatopathy (Rickels et al., 2022).
Pathophysiology: Destruction or loss of pancreatic tissue leads to loss of both endocrine (β-
cells, α-cells) and exocrine function. Insulin deficiency is primary, but glucagon deficiency
can also occur, altering the presentation (e.g., less ketosis, more hypoglycemia risk). Insulin
resistance may also be present, especially with inflammation or steatorrhea. CFRD involves
progressive β-cell destruction due to ductal obstruction, fibrosis, inflammation, and amyloid
deposition, compounded by insulin resistance during infections (Moran et al., 2020).
iii. Endocrinopathies:
Definition: Diabetes caused by excess counter-regulatory hormones antagonizing insulin
action.
Pathophysiology:
 Cushing's Syndrome: Excess cortisol promotes gluconeogenesis, induces insulin
resistance, and impairs β-cell function.
 Acromegaly: Excess growth hormone induces insulin resistance in muscle and liver.
 Pheochromocytoma: Excess catecholamines (epinephrine/norepinephrine) inhibit
insulin secretion and stimulate glycogenolysis/gluconeogenesis.
 Glucagonoma: Excess glucagon stimulates hepatic glucose output. Diabetes often
resolves with treatment of the underlying hormone excess (Fleseriu et al., 2021).
iv. Drug- or Chemical-Induced Diabetes:
Definition: Hyperglycemia caused by medications or toxins.
Pathophysiology: Mechanisms vary:
 Glucocorticoids: Induce hepatic insulin resistance (increased gluconeogenesis) and
peripheral insulin resistance; may also impair β-cell function.
 Atypical Antipsychotics (e.g., olanzapine, clozapine): Cause weight gain/obesity
and direct effects on insulin signaling and β-cell function.
 Calcineurin Inhibitors (e.g., tacrolimus, cyclosporine): Direct β-cell toxicity.
 Protease Inhibitors (HIV therapy): Cause lipodystrophy and insulin resistance.
 Others: Thiazides, β-blockers, niacin, pentamidine, L-asparaginase (Puckrin et al.,
2022).
v. Genetic Syndromes:
Definition: Diabetes occurring as part of a broader genetic disorder.
Examples and Pathophysiology:
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  Down Syndrome (Trisomy 21): Increased risk of T1DM and T2DM; mechanisms
include autoimmunity, obesity, and accelerated aging.
 Klinefelter Syndrome (XXY): Increased risk of T2DM linked to hypogonadism,
metabolic syndrome, and body composition changes.
 Turner Syndrome (45,X): Increased risk of T2DM and autoimmune diabetes;
associated with obesity, dyslipidemia, and often autoimmune thyroid disease.
 Prader-Willi Syndrome: Severe obesity due to hyperphagia is the primary driver of
insulin resistance and T2DM.
 Wolfram Syndrome (DIDMOAD): Autosomal recessive, caused by WFS1
mutations; characterized by diabetes insipidus, DM, optic atrophy, and deafness;
involves β-cell apoptosis and neurodegeneration (Nelson et al., 2019).

2.2. Risk Factors for Diabetes Mellitus in the Elderly Population

1. Advanced Age: Age is the single most potent risk factor for developing T2D. The
prevalence of diabetes rises dramatically with each decade of life after middle age.
Physiological Mechanisms:
 Insulin Resistance: Aging is intrinsically linked to a progressive decline in insulin
sensitivity. This occurs at multiple levels: reduced glucose uptake and utilization in skeletal
muscle (the primary site of insulin-mediated glucose disposal) due to mitochondrial
dysfunction, decreased muscle mass (sarcopenia), and alterations in insulin signaling
pathways (Smith et al., 2020).
 Epidemiological Evidence: Studies consistently show a sharp increase in diabetes
prevalence starting around age 45-50, peaking in the 65-79 age group. The Centers for
Disease Control and Prevention (CDC) estimates that approximately 29.2% of US adults
aged 65 or older have diagnosed or undiagnosed diabetes (CDC, 2023). Similar trends are
observed globally, particularly in rapidly aging societies.
2. Obesity and Body Composition Changes: Obesity, especially central
(abdominal/visceral) obesity, remains a paramount modifiable risk factor for T2D in all ages,
but its impact and manifestation in the elderly are distinct.
Visceral Adiposity: The accumulation of fat within the abdominal cavity and around internal
organs is highly metabolically active. It releases free fatty acids (FFAs) directly into the
portal circulation, promoting hepatic insulin resistance and increased gluconeogenesis.

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Sarcopenia and Sarcopenic Obesity: Age-related loss of skeletal muscle mass and strength
(sarcopenia) is a critical factor. Muscle is the primary site for insulin-stimulated glucose
disposal. Reduced muscle mass directly impairs glucose uptake.
Impact of Weight Gain: Weight gain during middle age significantly increases the risk of
developing T2D later in life. Even modest weight gain (5-10 kg) in older adults can
substantially elevate risk, particularly when associated with increased visceral fat (Lingvay et
al., 2019).
3. Physical Inactivity and Sedentary Behavior: Reduced physical activity levels are highly
prevalent in older adults and constitute a major independent and modifiable risk factor.
Mechanisms: Physical inactivity directly contributes to insulin resistance by reducing
glucose transporter (GLUT4) expression and activity in muscle, decreasing muscle mass,
promoting visceral fat accumulation, and impairing mitochondrial function (Cartee et al.,
2020). Sedentary behavior (prolonged sitting) independently exacerbates these risks.
Muscle Metabolism: Exercise, particularly resistance training, is crucial for maintaining
muscle mass (countering sarcopenia) and improving muscle insulin sensitivity. Aerobic
exercise enhances overall cardiorespiratory fitness and glucose utilization.
Epidemiology: Numerous cohort studies demonstrate a strong inverse relationship between
physical activity levels (both leisure-time and daily life activity) and the incidence of T2D in
older adults. Replacing sedentary time with light or moderate activity significantly reduces
risk (Dempsey et al., 2020).
Barriers: Age-related functional limitations (arthritis, balance issues, cardiopulmonary
disease), fear of injury, lack of access, and social isolation can hinder physical activity
participation in the elderly, creating a vicious cycle.
4. Genetic Predisposition: Family history remains a significant non-modifiable risk factor,
indicating the contribution of inherited genetic variants.
Polygenic Risk: T2D is a polygenic disorder. Genome-wide association studies (GWAS)
have identified hundreds of common genetic variants (single nucleotide polymorphisms -
SNPs), each conferring a small increase in risk. The cumulative effect of many risk alleles
contributes significantly to susceptibility (Mahajan et al., 2022). These genes often influence
beta-cell function (e.g., TCF7L2) or insulin action.
Gene-Environment Interactions: Genetic risk is not deterministic. Its expression is heavily
modified by lifestyle factors (diet, activity, obesity). An individual with high genetic
susceptibility can significantly delay or prevent T2D onset through healthy lifestyle choices,

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while an unfavorable environment can unmask genetic risk (Florez, 2019). This interaction is
crucial throughout life, including older age.
Ethnicity: Certain ethnic groups (e.g., African Americans, Hispanic/Latino Americans,
Native Americans, Asian Americans, Pacific Islanders) have a higher predisposition to T2D
at younger ages and lower BMIs compared to non-Hispanic whites. This increased risk
persists into older age and reflects complex interactions between genetics, epigenetics, and
socioeconomic/environmental factors (Chow et al., 2021).
5. Prediabetes and Metabolic Syndrome: These conditions represent a critical intermediate
stage on the pathway to frank T2D.
Prediabetes: Defined by impaired fasting glucose (IFG: fasting glucose 100-125 mg/dL),
impaired glucose tolerance (IGT: 2-hour post-OGTT glucose 140-199 mg/dL), or elevated
HbA1c (5.7-6.4%). A substantial proportion of older adults have prediabetes. Annual
progression rates from prediabetes to diabetes are significant, though potentially slightly
lower than in middle-aged adults, but the absolute number of conversions is high due to the
large at-risk elderly population (Hostalek et al., 2019). Prediabetes itself is associated with
increased cardiovascular risk.
Metabolic Syndrome (MetS): This cluster of cardiometabolic risk factors (central obesity,
elevated blood pressure, elevated fasting glucose, high triglycerides, low HDL cholesterol) is
highly prevalent in older adults. Having MetS dramatically increases the risk of progressing
to T2D and cardiovascular disease (CVD). Insulin resistance is the core pathophysiological
feature linking these components (Saklayen, 2021).
6. Other Contributing Factors
Smoking: Active smoking is a risk factor for T2D, contributing to insulin resistance and
inflammation. While many older adults quit, long-term former smokers may still have
residual risk (Pan et al., 2020).
Alcohol Consumption: Heavy alcohol consumption is associated with increased diabetes
risk and pancreatitis, which can damage beta-cells. Moderate alcohol intake *may* have a
complex relationship, potentially associated with slightly lower risk in some studies, but risks
often outweigh potential benefits, especially in older adults (Knott et al., 2020).
Gut Microbiome: Emerging evidence suggests age-related changes in gut microbiota
composition (dysbiosis) may influence host metabolism, inflammation, and insulin
sensitivity. Specific microbial signatures have been linked to T2D, though causality and
therapeutic implications are still under investigation (Tilg et al., 2020).

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History of Gestational Diabetes Mellitus (GDM): Women with a history of GDM have a
significantly increased lifetime risk of developing T2D, which extends into older age,
particularly if other risk factors like obesity are present (Vounzoulaki et al., 2020).

2.3. Implications for Prevention and Management

1. Screening and Early Detection: Regular screening for diabetes and prediabetes (using
FPG, HbA1c, or OGTT) is essential in older adults, especially those with multiple risk factors
(obesity, hypertension, family history, CVD). Screening tools might need adjustment for age-
related changes in HbA1c interpretation (ElSayed et al., 2023).
2. Lifestyle Interventions as Cornerstone: Intensive lifestyle programs focusing on
moderate weight loss (5-7%), healthy eating patterns (Mediterranean, DASH, plant-based),
and regular physical activity (combining aerobic and resistance training) are highly effective
in preventing or delaying T2D in high-risk older adults, including those with prediabetes
(American Diabetes Association, 2023). Interventions must be tailored to functional capacity
and comorbidities.
3. Addressing Sarcopenia: Incorporating resistance training and ensuring adequate protein
intake are critical for preserving muscle mass and metabolic health.
4. Comorbidity Management: Aggressive management of hypertension, dyslipidemia,
CVD, CKD, OSA, and depression is integral to reducing diabetes risk and complications.
5. Medication Review: Regular medication reconciliation to identify and minimize use of
drugs that adversely affect glucose metabolism, where possible and safe.
6. Psychosocial Support: Addressing social isolation, loneliness, depression, and
socioeconomic barriers is vital for promoting healthy behaviors and adherence to
management plans.
7. Personalized Medicine: Considering individual risk profiles, functional status, life
expectancy, comorbidities, and goals of care is paramount when making decisions about
screening intensity, treatment targets (e.g., HbA1c), and therapeutic approaches.

2.4. Management of Diabetes in Elderly Patients

Managing diabetes in elderly patients presents unique challenges due to the complex
interplay of aging-related physiological changes, comorbidities, and the risk of treatment-
related complications. A comprehensive and individualized approach is essential to optimize
glycemic control while minimizing adverse effects and preserving quality of life (American
Diabetes Association [ADA], 2021).
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1. Lifestyle Modification: Lifestyle intervention remains the cornerstone of diabetes
management in older adults. This includes tailored dietary modifications, regular physical
activity, and weight management. Nutritional recommendations focus on balanced meals that
prevent malnutrition and hypoglycemia, considering common age-related issues such as
decreased appetite and altered taste (Morley & Anker, 2020). Exercise programs should be
adapted to the individual’s functional capacity, emphasizing aerobic, resistance, and balance
exercises to improve insulin sensitivity, muscle strength, and reduce fall risk (Tanaka et al.,
2019).
2. Pharmacological Management: Pharmacotherapy in elderly diabetics requires
cautious selection and dosing of medications to avoid hypoglycemia, drug interactions, and
adverse effects due to polypharmacy. Metformin remains the first-line agent due to its
efficacy and cardiovascular benefits but should be used cautiously in patients with renal
impairment (ADA, 2021). Sulfonylureas and insulin secretagogues are generally avoided or
used with extreme care because of their hypoglycemia risk (Dunning et al., 2019).
Newer agents such as SGLT2 inhibitors and GLP-1 receptor agonists have gained favor for
their cardiovascular and renal protective effects and relatively low hypoglycemia risk
(McGuire et al., 2020). However, clinicians must monitor for side effects like dehydration
and gastrointestinal symptoms, which may be more pronounced in older adults. Insulin
therapy is often necessary for advanced diabetes but requires education on injection
techniques and hypoglycemia prevention (Munshi et al., 2017).
3. Monitoring and Glycemic Targets: Individualized glycemic targets are vital for
elderly patients, balancing benefits against risks. The ADA recommends less stringent
HbA1c goals (e.g., 7.5–8.0%) for those with limited life expectancy, cognitive impairment, or
multiple comorbidities to minimize hypoglycemia risk (ADA, 2021). Frequent blood glucose
monitoring helps tailor therapy and detect hypoglycemia early, especially in patients on
insulin or sulfonylureas (Inzucchi et al., 2015).
4. Geriatric Considerations: Elderly patients often present with cognitive decline,
frailty, and functional limitations that affect diabetes self-management. Cognitive impairment
can reduce the ability to adhere to complex medication regimens, necessitating caregiver
involvement and simplified treatment plans (Feil et al., 2019). Polypharmacy increases the
risk of adverse drug events; therefore, regular medication reviews are essential to deprescribe
unnecessary drugs and prevent interactions (Lai et al., 2021). Comorbidities such as
cardiovascular disease, chronic kidney disease, and sensory deficits require integrated care

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approaches. Multidisciplinary teams involving endocrinologists, geriatricians, dietitians, and
diabetes educators optimize outcomes (Vigersky et al., 2020).

2.5. Complications of Diabetes in Older Adults

Diabetes mellitus is a chronic metabolic disorder that becomes increasingly prevalent with
age. In older adults, diabetes poses a heightened risk of both microvascular and
macrovascular complications due to prolonged disease duration, comorbidities, and age-
related physiological decline (American Diabetes Association [ADA], 2022). Common
complications include cardiovascular disease, neuropathy, retinopathy, and nephropathy, each
significantly impairing quality of life and increasing mortality risk.
1. Cardiovascular Disease (CVD)
Cardiovascular complications remain the leading cause of death in older adults with diabetes.
Studies have shown that adults aged 65 and older with diabetes are two to four times more
likely to develop heart disease or suffer a stroke than those without diabetes (Virani et al.,
2020). Chronic hyperglycemia contributes to endothelial dysfunction, atherosclerosis, and
hypertension risk factors for myocardial infarction and cerebrovascular accidents. The
interplay of diabetes with dyslipidemia and obesity further compounds cardiovascular risks in
this population.
2. Peripheral Neuropathy
Diabetic peripheral neuropathy is highly prevalent in older adults, characterized by
numbness, tingling, pain, or weakness in the extremities. It results from long-standing
hyperglycemia damaging the peripheral nerves. This complication increases the risk of falls,
foot ulcers, and eventual lower limb amputation (Pop-Busui et al., 2017). Age-related sensory
decline may mask early symptoms, delaying diagnosis and management.
3. Retinopathy
Diabetic retinopathy is a leading cause of visual impairment among elderly diabetics. It
involves damage to the retinal blood vessels, resulting in microaneurysms, hemorrhages, and
in advanced stages, vision loss. A study by Cheung et al. (2019) found that nearly 30% of
older adults with diabetes exhibit some form of diabetic retinopathy. Visual impairment not
only affects independence but also contributes to depression and increased fall risk in the
elderly.
4. Nephropathy
Diabetic nephropathy or chronic kidney disease (CKD) is another significant complication,
often progressing silently. Persistent hyperglycemia leads to glomerular damage, proteinuria,
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and eventual decline in renal function. According to Thomas et al. (2021), nearly 40% of
elderly individuals with type 2 diabetes develop CKD, making routine screening essential.
The presence of kidney disease also limits the use of some antidiabetic drugs, complicating
management.
5. Multisystem Burden
Many older patients suffer from multiple complications simultaneously, resulting in
polypharmacy, functional decline, and increased hospitalization. Comorbid conditions such
as hypertension, cognitive impairment, and frailty further exacerbate outcomes and must be
addressed in a comprehensive care plan (Sinclair et al., 2020).

2.6. Impact of Diabetes on Quality of Life

Diabetes mellitus, particularly when poorly managed or accompanied by complications,
significantly affects the quality of life (QoL) of individuals, especially older adults. This
impact spans across physical health, emotional well-being, and social functioning, ultimately
influencing a person's ability to live fully and independently.
1. Physical Aspects
Physically, diabetes affects energy levels, mobility, and general functioning. Common
symptoms such as fatigue, frequent urination, and poor wound healing reduce daily
productivity (Kiadaliri et al., 2020). Over time, diabetes may lead to chronic complications
like neuropathy, retinopathy, and nephropathy, which limit physical independence. For older
adults, the risk of falls increases due to impaired vision or nerve damage, leading to reduced
physical activity and increased dependence (Alharbi et al., 2020).
Glycemic control plays a vital role in preserving physical function. Patients with uncontrolled
blood sugar often report more pain, reduced sleep quality, and poorer general health. As
noted by Wändell et al. (2019), older patients with diabetes and comorbidities have a
significantly lower physical component score in QoL assessments compared to those without
diabetes.
2. Emotional and Psychological Impact
The emotional burden of diabetes is profound. Many patients live with anxiety, fear of
complications, and frustration from daily disease management routines. Depression is
common among diabetic patients, with studies indicating that people with diabetes are twice
as likely to suffer from depressive symptoms compared to the general population (Bailey et
al., 2018). This psychological toll may arise from the continuous stress of monitoring
glucose, adhering to dietary restrictions, and the fear of future complications.
15
Moreover, emotional distress, often called "diabetes distress," is linked to poor self-care
behaviors and worse glycemic outcomes (Fisher et al., 2020). Elderly patients especially may
struggle with feelings of helplessness or social isolation due to physical limitations and
reduced social engagement.
3. Social Aspects
Socially, diabetes can limit participation in normal activities. Dietary restrictions can make
social gatherings difficult. Frequent medical appointments or illness episodes may interfere
with work, religious involvement, or community events. In some cases, elderly individuals
may withdraw due to embarrassment or inconvenience, reducing their social network and
support system (Abdelhafiz & Sinclair, 2020).
In resource-limited settings like rural areas of Nigeria, social impact is compounded by
limited access to care and stigma surrounding chronic illness. Inadequate education on
diabetes management may further isolate individuals from their families and communities,
especially if they become dependent on others for care (Chinenye & Young, 2020).

2.7. Role of Primary Healthcare in Diabetes Management

Primary healthcare (PHC) plays an importance role in the effective management of diabetes,
especially in low- and middle-income countries like Nigeria. As the first point of contact
within the healthcare system, PHC providers are strategically positioned to carry out
community outreach, promote early detection, and ensure consistent follow-up for individuals
living with diabetes.
1. Community Outreach
One of the most critical roles of PHC in diabetes management is health education and
community outreach. Through awareness campaigns and educational programs, PHC teams
can inform the public about diabetes risk factors, preventive lifestyle practices, and the
importance of routine screening (Abdulrahman et al., 2019). In rural communities, where
health literacy is often low, these outreach activities help dispel myths and empower
individuals to make informed health decisions. PHC workers, including community health
extension workers (CHEWs), also serve as trusted figures who bridge the gap between formal
healthcare and community members (Ameh et al., 2020).
2. Early Detection and Diagnosis
Early diagnosis is key to preventing complications associated with diabetes. PHC centers are
strategically located and accessible, making them ideal for routine screening of at-risk
populations. By integrating diabetes screening into regular visits, especially for individuals
16
over 40, the obese, or those with family history, PHC can identify cases earlier (Ogunsola et
al., 2022). Blood glucose tests and risk assessments can be conducted quickly and affordably
in these centers, helping to catch the disease before severe symptoms or complications
develop.
3. Treatment and Monitoring
Once diagnosed, PHC providers offer essential diabetes management services, including
prescribing medications, monitoring glucose levels, and counseling patients on diet and
physical activity. Importantly, PHC promotes a patient-centered model, allowing for
individualized care plans that are culturally sensitive and tailored to local realities (Chinenye
& Uloko, 2019). Consistent follow-up appointments help ensure medication adherence,
monitor progress, and adjust treatment where necessary.
4. Coordination and Referral
PHC serves as a hub for coordinating care. When complications arise such as diabetic foot
ulcers or signs of nephropathy, PHC centers refer patients to higher levels of care. This
ensures that patients receive specialized attention while maintaining continuity of care at the
primary level. Referral systems also enable efficient use of healthcare resources by managing
uncomplicated cases within the community (World Health Organization, 2021).
5. Challenges and Opportunities
Despite its importance, the role of PHC in diabetes management faces challenges, including
inadequate staffing, lack of training in chronic disease care, and insufficient equipment.
However, strengthening PHC through policy support, continuous training, and integration of
technology (e.g., mobile health tools) offers promising solutions (Fasanmade et al., 2020).

2.8. Barriers to Diabetes Care in Rural Communities

Rural communities face significant challenges in accessing adequate diabetes care,
particularly in low- and middle-income countries like Nigeria. These barriers, including
poverty, low health literacy, and inadequate health infrastructure, significantly affect the
prevention, management, and outcomes of diabetes mellitus among rural populations.
1. Poverty and Financial Constraints
Poverty is one of the most significant barriers to healthcare access in rural communities. The
cost of diabetes care including consultation fees, laboratory tests, medications, and
transportation is often beyond the financial capacity of many individuals living in rural areas
(Adeloye et al., 2021). As a result, patients may skip regular check-ups or resort to traditional
remedies, which delays effective treatment and increases the risk of complications.
17
Studies show that out-of-pocket spending on health care is prevalent in Nigeria, with only
limited support from national health insurance, which remains largely inaccessible to rural
dwellers (Ameh et al., 2019). Furthermore, many rural households prioritize immediate
survival needs over long-term health management, leading to poor disease control and
increased mortality.

2. Low Health Literacy

Health literacy refers to an individual’s capacity to obtain, understand, and use health
information to make appropriate health decisions. In many rural settings, especially among
older adults, health literacy remains very low (Ekpenyong & Udoh, 2019). This affects not
only the ability to recognize symptoms of diabetes but also the understanding of medical
advice, medication use, and the importance of lifestyle changes.
Low health literacy is linked to misconceptions about diabetes, such as believing it is caused
solely by spiritual factors or only curable through herbal treatment (Uchenna et al., 2020).
Such beliefs contribute to poor adherence to medical regimens and delay in seeking formal
healthcare. Health education campaigns are often not effectively tailored to the rural context,
further limiting their impact.
3. Inadequate Health Infrastructure
Infrastructural deficits are a persistent barrier in rural health systems. Many primary
healthcare centers in rural communities lack basic diagnostic tools, essential medications, and
trained healthcare personnel to manage chronic diseases like diabetes (Fasanmade et al.,
2020). Patients may have to travel long distances to access facilities equipped to manage their
condition, creating delays and discouraging regular follow-up.
Moreover, referral systems are weak or non-functional in many rural areas. Even when
complications arise, patients often remain at the primary level due to lack of transportation,
high costs, or lack of knowledge about specialized care (WHO, 2021). The shortage of
trained healthcare professionals, including doctors and nurses, also limits the ability of rural
health systems to provide quality and consistent diabetes care.
4. Cultural and Social Factors
Cultural norms and beliefs also influence diabetes care in rural communities. In some cases,
stigma associated with chronic illnesses can lead to secrecy or denial, preventing patients
from seeking help (Adewoyin et al., 2019). Others may prefer traditional healers or religious
interventions due to cultural familiarity or distrust in modern healthcare systems.
18
Family dynamics also play a role. In rural African settings, decision-making about health is
often communal. If family members do not support medical treatment, individuals may
abandon prescribed therapies. Women, in particular, may face additional challenges if they
lack financial independence or are restricted in their mobility by cultural expectations.
5. Limited Awareness and Screening
Many rural residents are unaware of the risk factors and early signs of diabetes. Without
regular community-based screening programs, diabetes is often diagnosed only when severe
symptoms or complications arise. This late detection contributes to poor outcomes and a
higher burden on healthcare services (Ogunyemi et al., 2021).
Public health campaigns about non-communicable diseases tend to focus more on urban
populations, where mass media and digital outreach are more accessible. Rural areas are
often excluded from such initiatives due to logistical challenges and lack of tailored
communication strategies.
6. Technological Gaps
With the rise of digital health tools, urban populations have benefitted from telemedicine,
mobile health (mHealth) apps, and electronic record systems. However, rural communities
often lack access to reliable internet, smartphones, or even electricity, making it difficult to
integrate these innovations into care delivery (Oladele et al., 2022).

19
 CHAPTER THREE
SELECTED CASE (MRS. WUNMI BAMIDELE)

3.0. Patient Bio-data

 Full Name: Mrs. Wunmi Bamidele
 Age: 45 years
 Sex: Female
 Residential Address: No 5, Akindoyin Street, Eleyele, Ibadan, Oyo State.
 Marital Status: Married
 Religion: Islamic
 Tribe: Yoruba (native language: Yoruba; fluent in pidgin English).
 Occupation: Trading
 Next of Kin: Husband, Mr. Bamidele Adeyemi (52 years old; civil servant).
 Relationship: Spouse
 Primary Diagnosis: Cataracts.

3.1. Description of the Patient

Mrs. Bamidele is a middle-aged Yoruba woman of average height (1.63m) averagely built
(weight: 75kg; BMI: 28.2). She presented with a warm demeanor but visible anxiety about
her declining vision. Her clothing is modest, consistent with her Islamic faith, as she wore a
neatly tied hijab and a long-sleeved Ankara gown. Throughout our discussion, she squinted
frequently, struggling to maintain eye contact, and often tilted her head to adjust her visual
focus. Notably, her hands were calloused from years of sorting and washing second-hand
clothes, and she gripped a small Quran tucked into her handbag.

3.2. Initial Contact and Establishment of Rapport with Mrs. Wunmi Bamidele

20
My first encounter with Mrs. Bamidele was at Ori-eru Primary Health Care Center during my
practical training. She was accompanied by her husband, who guided her by the arm as they
walked into the clinic. Mrs. Bamidele was a 45-year-old woman with a composed demeanor,
despite her obvious visual impairment due to cataract. She wore an Ankara dress, which
added a touch of vibrant color to her appearance. Her husband's supportive gesture was
evident as he helped her navigate the clinic.
As I approached her, I greeted her warmly in Yoruba language, "Ekaaro Ma?" (Good
Morning, Ma?). She responded with a smile, "Kaaro, eku ise eni" (Morning, well-done). I
asked her how she was doing, and she replied, "Mo wa dada, o se" (I'm good, thank you).
This initial exchange helped establish a rapport with her.
I then asked Mrs. Bamidele about the purpose of her visit to the clinic, and she explained her
complaints about her vision problems. Her husband occasionally interjected to provide
additional context, demonstrating their collaborative approach to addressing her health
concerns.
The Ori-eru Primary Health Care Center, where I met My client, is a facility that provides
essential healthcare services to the community. On that day, the clinic was bustling with
patients seeking medical attention for various health issues. The atmosphere was calm and
organized, with healthcare professionals attending to patients with care and compassion.
This initial encounter with my client marked the beginning of our interaction, and I was able
to establish a rapport with her through a warm greeting and gentle conversation. Her
husband's presence and support played a significant role in her comfort and confidence
during our interaction.

3.3. JCHEW Assessment

3.3.1. Previous Medical History
When I asked Mrs. Wunmi Bamidele about her previous medical history, she informed me
that she does not have any known previous medical conditions, stating "I have never been
hospitalized or treated for any major illness before, except for the normal childhood illnesses
that most children experience, and I've never had any surgeries or injuries that required
medical attention." She further emphasized that she has always been a healthy person and has
never had any chronic illnesses.
3.3.2. Present Medical History
Mrs. Wunmi Bamidele reported that she has been experiencing a gradual decline in her vision
over the past six months, with symptoms including blurry vision, difficulty seeing at night,
21
and sensitivity to light. She mentioned that her symptoms started with slight blurriness when
reading and gradually worsened, affecting her daily activities. She stated, "At first, I thought
it was just a minor issue with my eyes, but as time went on, I realized it was more serious
than that."
3.3.3. Physical Examination
Upon conducting a physical examination, Mrs. Bamidele appeared well-groomed but
fatigued. There were no signs of pallor or jaundice. Her vital signs were as follows: blood
pressure was slightly elevated at 130/85 mmHg, pulse was 78 beats per minute with a regular
rhythm, respiratory rate was 16 breaths per minute, and her temperature was 36.8°C. The
ocular assessment revealed a visual acuity of 20/80 in both eyes, as measured by the Snellen
chart. A slit-lamp examination confirmed nuclear opacities in both lenses, more pronounced
in the right eye. Her pupillary reflex was brisk but with reported glare intolerance.
Fundoscopy showed that the retina and optic nerve appeared normal, with no signs of
diabetic retinopathy. The systemic review was unremarkable, with no joint pain, chest pain,
or shortness of breath reported.
3.3.4. Family and Social History
Mrs. Bamidele shared with me her family structure, telling me that she is married with three
children: two sons, aged 14 and 10, and one daughter, aged 16. She relies heavily on her
eldest daughter for support, particularly in the market, where her daughter helps identify
clothing quality and prices. Her husband also assists by lifting heavy bales of clothes. In
terms of family medical history, Mrs. Bamidele's mother was diagnosed with hypertension at
the age of 60 and is managed with medication. Her father, unfortunately, passed away at 68
due to stroke-related complications. There is no known family history of cataracts or
congenital eye disorders. Within her community, Mrs. Bamidele is active in her local
mosque's women's group and is well-known in the Okrika market for her honesty and
bargaining skills.

3.4. Accommodation and Pattern of Living

Mrs. Bamidele described her home environment as a 3-bedroom bungalow with her family.
The house is dimly lit, with narrow hallways cluttered by stacked bales of unsorted Okrika
clothing. Her daily routine begins at 5:00 AM with dawn prayer (Fajr), followed by sorting
through newly acquired second-hand clothes in her backyard, where she relies on touch to
identify fabric types. From 8:00 AM to 6:00 PM, she sells clothes at the bustling Okrika
market, where she struggles to differentiate colors and patterns, leading to pricing errors. In
22
the evening, she depends on her daughter to tally earnings and organize stock. For
transportation, Mrs. Bamidele uses commercial motorcycles (okada) and avoids night travel
due to glare from vehicle headlights.
3.4.1. Nutritional-Metabolic Pattern
Mrs. Bamidele's typical diet consists of irregular meals due to market demands. Her breakfast
often includes leftover rice with beans (ewa rice), lunch might be amala with bitter leaf soup
(rarely including meat due to cost), and dinner could be garri soaked in water with fried
groundnuts. Her fluid intake is approximately 1-1.5 liters daily, mostly water and sugary malt
drinks. Given her dietary habits, there is a suspected low intake of vitamins A and C, which
are critical for eye health.
3.4.2. Elimination Pattern
Mrs. Bamidele reported having regular bowel movements once daily without the use of
laxatives. She urinates 4-5 times a day without experiencing dysuria or urgency.
3.4.3. Activity-Exercise Pattern
As an Okrika trader, Mrs. Bamidele stands for 10-12 hours a day at her market stall,
performing repetitive motions such as folding clothes and haggling. Due to her poor vision,
she is unable to thread needles for clothing repairs or read customer receipts, significantly
limiting her functional abilities.
3.4.4. Sleep-Rest Pattern
My client’s sleeping quality is poor, averaging 5-6 hours per night. Her sleep is often
disrupted by worries about financial losses due to her poor vision.
3.4.5. Self-Perception/Self-Concept
Mrs. Wunmi Bamidele expressed feelings of frustration and anxiety about her vision loss,
stating "I'm worried about what will happen to me if I lose my sight completely, and I'm
scared about the impact it will have on my daily life and relationships." She also mentioned
that she feels like she's losing her independence.
3.4.6. Role-Relationship Pattern
Mrs. Wunmi Bamidele mentioned that her vision problems have affected her relationships
with her family and friends, stating "I feel like I'm a burden to my family because I need help
with everything now, and I'm worried about how they'll manage if my condition worsens."
She also mentioned that she's had to rely on others for assistance with daily tasks..
3.4.7. Coping-Stress Tolerance
When I asked about her coping mechanisms, Mrs. Wunmi Bamidele reported that she tries to
manage her stress by praying and talking to her family members. She stated, "I pray a lot and
23
talk to my husband and children about my concerns, and they try to reassure me and offer
support." She also mentioned that she tries to stay positive and focus on her faith.
3.4.8. Value-Belief Pattern
Mrs. Bamidele adheres to certain cultural practices, such as refusing male clinicians during
physical exams unless her husband is present. She believes that "Allah will reward patience"
but acknowledges the need for medical intervention to address her health issues.

CHAPTER FOUR
4.0. HOME VISIT RAPPORT AND CLIENT MANAGEMENT
On a sunny afternoon, April 18, 2025, I arrived at Mrs. Bamidele's house, a 45-year-old
woman with cataract. As I approached her home, I took a moment to reflect on the
significance of this visit. Our initial encounter at the Orieru Primary Health Care Center had
laid the foundation for our interaction, and I was eager to build on that rapport.
I knocked on the door, and after a brief moment, it swung open. Mrs. Bamidele stood before
me, her eyes squinting slightly, and a warm smile spreading across her face. Though she
looked a bit unsure about my visit, her demeanor was welcoming. I greeted her warmly,
“Good Afternoon, Ma”, she replied with a gentle smile, "Afternoon, my daughter".
I introduced myself, reminding her of our first encounter at the health center, and explained
the purpose of my home visit. "Mrs. Bamidele, I'm here to provide support and education
about your cataract, and help you with your treatment plan. I'm committed to ensuring that
you receive the best possible care, and I want to assure you that everything we discuss will
remain confidential." I reassured her that my goal was to empower her with knowledge and
support, not to intrude or impose.
Mrs. Bamidele listened attentively, her expression transforming from uncertainty to
understanding. She nodded, and I asked if she was comfortable with me supporting her and
educating her on her current health issue. She agreed, and with a gentle gesture, she led me
into her living room.
As we sat down, I began by asking how she was feeling currently and about her progress with
cataract. "How have you been feeling since our last meeting, Mrs. Bamidele? Have you
noticed any changes in your vision or experienced any discomfort?" Initially, she hesitated,
her responses brief and guarded. However, as our conversation progressed, she began to open
up about her symptoms and the emotional toll the diagnosis had taken on her.

24
I listened attentively, offering empathy and reassurance throughout the visit. My friendly and
non-judgmental attitude created a safe space for her to express her thoughts and feelings. I
encouraged her to ask questions and actively participate in her care, ensuring that she felt
empowered and informed.
As we chatted, her husband and one of their children emerged from their room, greeting me
warmly. The atmosphere in the home was welcoming, and I appreciated the opportunity to
interact with Mrs. Bamidele's family. After our discussion, they offered me food, which I
politely declined, thanking them for their hospitality.
Before leaving, I scheduled a follow-up visit and provided Mrs. Bamidele with my contact
information for any additional questions or concerns. I reassured her that she wasn't alone in
this journey, that there was a support system in place to help her through this challenging
time. With gratitude, I bid them goodbye, appreciating their openness and cooperation.
Evaluation: As I departed, I reflected on the significance of this visit. Building trust and
rapport with Mrs. Bamidele was crucial in ensuring her comfort and adherence to her
treatment plan. I was confident that our interaction would have a positive impact on her
journey, and I looked forward to our next meeting.

4.2. SECOND HOME VISIT ON 28TH APRIL, 2025

On April 28, 2025, I conducted my second home visit to Mrs. Bamidele, a 45-year-old
woman with cataract. During this visit, I focused on assessing her progress, addressing
concerns, and providing ongoing support and education.
As I arrived at her home, I was greeted by a more relaxed and hopeful-looking Mrs.
Bamidele. We sat down in their visiting room, and I began by asking her how she had been
feeling since my last visit. Mrs. Bamidele shared that she had been taking antibiotics
prescribed by her physician and had noticed a slight improvement in her symptoms.
However, she mentioned experiencing some side effects, such as eye irritation and fatigue.
I listened attentively, acknowledging her concerns and assuring her that these side effects
were not uncommon. I explained that it was essential to continue her treatment as prescribed
and that I would monitor her progress closely. Mrs. Bamidele expressed concern about the
potential long-term effects of cataract surgery and the impact it might have on her daily life.
She worried about the possibility of complications and the need for additional surgeries.
I addressed her concerns by providing reassurance and explaining the importance of
completing her treatment to reduce the risk of complications. I emphasized that regular
follow-up appointments with her healthcare provider would help monitor her condition and
25
address any issues promptly. I also discussed the importance of proper eye care, advising her
against touching her eyes with her hands, as this could contaminate her eyes and potentially
lead to infection. I explained that cataract is a condition that requires surgical intervention
and that glasses would not correct her vision problem.
Regarding her concern about putting her hands in her eyes, I educated her on the risks of
contaminating her eyes and potentially hastening the spread of infection. I stressed the
importance of maintaining good hygiene practices and avoiding actions that could
compromise her eye health.
Furthermore, I emphasized the need for regular follow-up appointments with her healthcare
provider for monitoring and evaluation. I encouraged Mrs. Bamidele to ask questions and
express any worries she might have, ensuring that she felt supported throughout her journey.
In addition to medical support, I highlighted the importance of self-care and offered resources
for support groups or counseling if she felt overwhelmed. I reassured her that she was not
alone and that there were resources available to help her cope with the emotional aspects of
her condition.
Notably, her cataract surgery is scheduled to take place on April 31, 2025. I explained the
preparations and expectations for the surgery, and Mrs. Bamidele seemed more confident and
prepared for the procedure. Following the surgery, I will continue with follow-up visits to
monitor her recovery and provide ongoing support.
As our conversation progressed, I was pleased to see Mrs. Bamidele's understanding and
willingness to adhere to her treatment plan. I scheduled another follow-up visit and
encouraged her to reach out if she had any further questions or concerns. With a renewed
sense of hope and determination, Mrs. Bamidele thanked me for my support, and I bid her a
warm goodbye.
Evaluation: This visit reinforced the importance of ongoing support and education in
managing Mrs. Bamidele's condition. I was confident that with continued care and adherence
to her treatment plan, she would navigate her journey with cataract more effectively. I look
forward to our next interaction, particularly the scheduled surgery and subsequent follow-up
visits, where I will continue to provide support and monitor her progress closely.

4.3. THIRD HOME VISIT ON 12TH MAY, 2025.

On May 12, 2025, I conducted my third home visit to Mrs. Bamidele, a 45-year-old woman
with cataract. Upon arrival, I asked her about her feelings and experience since the surgery.
She expressed gratitude, stating that the surgery was successful and had alleviated the pain
26
and discomfort she previously felt. However, she mentioned experiencing some itching in her
eyes. I reassured her that this was a normal post-surgery symptom.
Mrs. Bamidele also mentioned that if she had known the surgery would be this beneficial, she
would have undergone it earlier. I was pleased to see her recovery progressing well, and I
continued to provide support and education on post-operative care. Our conversation
reinforced the importance of follow-up visits in ensuring her continued recovery and
addressing any concerns she may have.

4.4. Health Education

During our discussions, I emphasized the importance of post-surgical care and recovery. I
educated Mrs. Bamidele on what to expect after cataract surgery, including potential
symptoms such as itching, mild discomfort, and sensitivity to light. I reassured her that these
symptoms are normal and typically subside within a few days.
I also advised her on how to manage these symptoms, including using prescribed eye drops,
avoiding rubbing her eyes, and wearing sunglasses to protect her eyes from bright light.
Additionally, I stressed the importance of follow-up appointments to monitor her recovery
and address any concerns she may have.
Regarding cataract prevention, I informed Mrs. Bamidele that cataracts are a common age-
related condition, but certain factors can increase the risk, such as UV exposure, smoking,
and diabetes. I encouraged her to maintain a healthy lifestyle, including a balanced diet rich
in fruits and vegetables, and regular eye check-ups to monitor her eye health.
I also took this opportunity to reassure her that cataracts are a treatable condition and that
many people have successful surgeries with significant improvements in their vision and
quality of life. By understanding her condition and adhering to post-surgical care instructions,
Mrs. Bamidele can optimize her recovery and enjoy improved vision.
Some key points I emphasized include:
 The importance of using prescribed eye drops as directed
 Avoiding heavy lifting, bending, or strenuous activities
 Protecting her eyes from dust and debris
 Attending follow-up appointments as scheduled
 Maintaining a healthy lifestyle to support overall eye health

4.5. Drug Regimen

27
S/N DRUG (Class) DOSAGE ACTION DURATION
(Frequency) (Typical Range)

1. Antibiotic (e.g., 1 drop, 4 times daily Prevents 1-2 weeks post-

Moxifloxacin 0.5%, (QID) bacterial op. Often
Gatifloxacin 0.3%, infection. stopped first.
Besifloxacin 0.6%, Ofloxacin Prophylaxis
0.3%, Chloramphenicol 0.5%) against
endophthalmitis.
2. Corticosteroid (e.g., 1 drop, 4 times daily Reduces post- 2-6 weeks post-
Prednisolone Acetate 1%, (QID). May start surgical op. Requires
Dexamethasone 0.1%, higher (e.g., every 2 inflammation, gradual tapering
Loteprednol Etabonate 0.5%, hours) & taper. pain, and (e.g., reduce by
Fluorometholone 0.1%) prevents cystoid 1 drop per
macular edema week).
(CME).
3. NSAID (Non-Steroidal Anti- 1 drop, 2-3 times daily Reduces Often 2-6 weeks
Inflammatory Drug) (e.g., (BID/TID). Sometimes inflammation post-op.
Ketorolac 0.4%/0.5%, QID. and pain; helps Sometimes
Bromfenac 0.07%/0.09%, prevent/treat continued longer
Nepafenac 0.1%/0.3%, CME; helps than steroid.
Diclofenac 0.1%) stabilize the
pupil.
4. Mydriatic/Cycloplegic (e.g., 1 drop, 1-3 times daily Dilates pupil Usually short-
Atropine 1%, Cyclopentolate (QD/TID) as needed (mydriatic), term (a few days
1%, Homatropine 2%) paralyzes to a week), as
accommodation directed.
(cycloplegic),
reduces pain
from ciliary
spasm. Used if
significant
inflammation or
iris

28
 manipulation
occurred.

Important Considerations & Notes:

1. Patient Instructions:
 Wash hands before using drops.
 Wait at least 5 minutes between instilling different drops to prevent wash-out and allow
absorption.
 Gently close eyes or press on the tear duct (nasolacrimal occlusion) for 1-2 minutes after
instilling drops (especially steroids) to minimize systemic absorption.
 If using multiple drops, a typical order is: Antibiotic -> NSAID -> Steroid. (But confirm
specific order with surgeon/pharmacist).
 Report significant pain, worsening redness, decreased vision, or increased sensitivity to
light immediately.
2. Side Effects:
 Steroids: Potential for increased intraocular pressure (IOP - glaucoma risk), cataract
formation (long-term), delayed wound healing, increased infection risk. Tapering
minimizes some risks.
 NSAIDs: Generally well tolerated topically. Can cause transient stinging/burning. Rarely,
corneal melting (more associated with older agents/dry eye).
 Antibiotics: Transient stinging/burning, allergic reactions (less common topically).
 Cycloplegics: Blurred near vision, sensitivity to light.

29
 CHAPTER FIVE
5.0. SUMMARY, ADVICE, FOLLOW-UP CARE, AND CONCLUSION
5.1. Summary of the Case Study
This case study documented the journey of Mrs. Wunmi Bamidele, a 45-year-old Yoruba
woman, Islamic faithful, and Okrika clothes trader from Ibadan, diagnosed with bilateral
nuclear cataracts. The cataracts caused significant visual impairment (VA 20/80 bilaterally),
manifesting as blurry vision, night blindness, glare sensitivity, and difficulty differentiating
colors and patterns. This severely impacted her core livelihood activities in the market,
leading to pricing errors, financial losses, and dependence on her daughter. Psychosocially,
Mrs. Bamidele experienced considerable anxiety, frustration, fear of complete blindness, loss
of independence, and feelings of being a burden on her family, particularly her husband and
eldest daughter.
Following diagnosis at Ori-eru Primary Health Care Center, a series of three home visits were
conducted to establish rapport, provide education, address concerns, and support her through
the treatment pathway. Initial anxieties regarding surgery were significant, stemming from
fear of complications, financial implications, and loss of control. Through empathetic
counseling, clear communication about the procedure and post-operative care, and involving
her supportive family, Mrs. Bamidele consented to surgery. The cataract surgery was
successfully performed and resulted in significant alleviation of her symptoms and improved
vision. Post-operatively, she reported relief from discomfort and expressed regret for not
seeking intervention sooner, although experiencing expected minor symptoms like itching.

5.2. Advice to the Patient (Mrs. Wunmi Bamidele)

1. Strict Adherence to Medication: It is crucial to use your prescribed eye drops exactly as
directed by your doctor. Do not stop them early, even if your eye feels better. Remember:
 Wash hands thoroughly before touching your eyes or the dropper.
30
  Instill drops in the correct order (as instructed - typically Antibiotic -> NSAID ->
Steroid) and wait at least 5 minutes between different drops.
 Gently press on the inner corner of your eye (tear duct) for 1-2 minutes after putting
in steroid drops.
 Complete the full course of all medications.

2. Eye Protection and Hygiene:

DO NOT RUB OR TOUCH YOUR EYES: This can cause serious injury or infection.
 Wear the protective eye shield, especially while sleeping, for the duration advised by
your doctor (usually the first week).
 Wear sunglasses outdoors to protect against bright light and UV rays, which are
harmful.
 Avoid getting soap, shampoo, or dirty water in your eyes for at least the first week.
Wash your face carefully.
 Avoid dusty or smoky environments if possible.
3. Activity Restrictions:
 Avoid heavy lifting (like bales of clothes), strenuous activity, bending over at the
waist, or straining for at least 2-4 weeks, or as long as your doctor advises. This helps
prevent pressure on the healing eye.
 Be cautious when moving around to avoid bumps or falls.
4. Recognize Warning Signs: Contact your eye doctor or go to the health center
immediately if you experience:
 Significant increase in pain (beyond mild discomfort/itching).
 Worsening redness in the eye.
 Sudden decrease in vision.
 Increased sensitivity to light (photophobia).
 New floaters (black spots) or flashes of light.
 Any discharge from the eye.
5. Attend All Follow-Up Appointments: These visits are essential for the doctor to check
your healing, monitor for complications, and ensure the best possible outcome. Do not miss
them.

5.3. Follow-Up Care Plan For Mrs Bamidele (Post-Cataract Surgery)

31
1. Day 1 Check-Up: Visit the clinic/hospital the day after surgery.
Reason: To make sure the eye is healing properly right away and adjust medications if
needed.
2. Week 1 Check-Up: Visit the clinic 1 week after surgery.
Reason: To check healing and eye pressure (important if using steroid drops), and likely
start reducing the number of steroid eye drops safely.
3. Month 1 Check-Up: Visit the clinic 1 month after surgery.
Reason: For a full eye exam and vision test. This is when you'll likely get a prescription for
new glasses (if needed) to see your best for work and daily life.
4. Yearly Eye Exams: Get a full eye check-up every year for life.
Reason:To monitor the long-term health of both eyes, catch any new problems early (like
glaucoma or cataract in the other eye), and keep your vision clear.

5.4. Conclusion
Mrs. Wunmi Bamidele's case vividly illustrates the profound impact cataracts can have on a
relatively young, economically active individual in a resource-constrained setting. Her
experience highlights not only the physical burden of progressive vision loss but also the
significant psychosocial and economic consequences, threatening livelihood, independence,
and family dynamics. The successful management of her condition through cataract surgery
underscores this procedure as a highly effective and sight-restoring intervention.
This case study achieved its objectives:
1. Clinical Presentation & Severity: Documented the typical symptoms (blurriness, glare,
night blindness) and functional impact (inability to price goods, thread needles, travel safely
at night) of significant bilateral nuclear cataracts in a mid-aged adult.
2. Treatment Effectiveness: Demonstrated the clear effectiveness of modern cataract
surgery in resolving symptoms and improving functional vision, significantly enhancing
quality of life and independence. Mrs. Bamidele's post-operative relief and regret for delayed
intervention powerfully attest to this.
3. Psychosocial Impact: Revealed the substantial anxiety, fear, frustration, and perceived
loss of independence caused by cataract-related vision impairment. It highlighted the crucial
role of family support (husband, daughter) and faith in coping, and the positive shift in
outlook following successful treatment.

32
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