Diabetes in the Older Patient

1. Diabetes in the Older Patient Debra Bynum, MD Associate Professor of Medicine Division of Geriatric Medicine University of North Carolina March 2010

2. True or False? • 1. A healthy 90 year old woman is likely to live to be 95… • 2. Obesity is associated with increased mortality in people over the age of 70 • 3. Patients over the age of 80 with systolic hypertension should not be treated because of an increased risk of falls

3. Outline • Prevalence • Heterogeneity (Patients and Disease) • Specific complications • Diabetes and Geriatric Syndromes • Diabetes in the Frail • Obesity in the Older Patient • Treatment Basics • Take Home Points

4. Focus • How is diabetes different in the older patient?

5. Prevalence • Majority of patients with DM are over age 60 • >10% patients over age 65 have DM • >10% over age 60 may have undiagnosed DM • CDC estimates prevalence of DM: 23% (diagnosed and undiagnosed) in people over 60 • Framingham Data: 40% those over 65 have DM or Impaired Fasting Glucose

6. Heterogeneity: Patients • Average Life expectancy 72-79 • At age 65, average life expectancy 82 • At age 85, average life expectancy 90 • Fastest growing population: over 85 • Differences • Age (65, 75, 85, 95, 100) • Frailty and age are not equal • Associated co-morbidities

7. Heterogeneity: Disease • Patients with long standing Type 2 Diabetes associated with family history, obesity, and metabolic syndrome • Latent Autoimmune Diabetes in Adults (LADA) • Patients with long standing Type 2 DM with no family history and normal BMI • Patients with new diagnosis of DM after age 60 • Growing population of Patients over age 60 with longstanding Type 1 Diabetes

8. LADA • Autoimmune (antibodies present at diagnosis) • Resembles type I diabetes • Later onset (after age 30) • Slower progression toward absolute insulin requirement (presentation with ketosis uncommon)

9. Complications

10. Hyperglycemia • Dehydration • Increased risk in elderly • Decreased oral intake, decreased thirst mechanism • Visual disturbance • Confusion

11. Nonketotic Hyperglycemic Hyperosmolar Coma • Extremely high glucose in setting of extreme dehydration • Often associated with infection, myocardial event, stroke • More common than DKA in older adults • Higher mortality • Older patients with dementia, decreased access to free water (nursing care setting), and decreased thirst are at higher risk

12. Hypoglycemia • Risk Factors: • Older age • Renal insufficiency • Long acting oral agents (sulfonylureas) • Poor nutrition • Alcohol use • CHF • Post hospitalization/ frequent hospitalizations • Polypharmacy

13. Hypoglycemia • Risk 2-9% in cohort studies • ?association with later development of dementia • Cohort study of patients followed over 20 years • Patients with at least one episode of severe hypoglycemia had increased risk of development of diabetes • May be confounder and not causal… • JAMA 2009

14. Nephropathy • Overall increase prevalence of Renal Insufficiency and ESRD in older patients • Older patients may have multiple etiologies for renal failure (DM, HTN, medications) • Microalbuminuria common (over 30%) and not as predictive of future ESRD in older patients • Highly predictive of CV and stroke risk • ACE inhibitors still recommended

15. Renal Insufficiency • “Normal Creatinine” may not be normal • Calculate GFR • GFR depends upon age, weight, sex • Creatinine of 1.1 in an 80 pound woman who weighs 98 pounds is not “normal”

16. Visual Loss • Often multifactorial • Retinopathy often less progressive than in younger patients with DM • Glaucoma three times more common in older patients with DM (11% vs 4%) • Cataracts more common and more rapidly progressive

17. Foot Care • Neuropathy • Common and not always due to DM in older patients (50% patients over 80 have peripheral neuropathy) • 1/3 older patients cannot see/reach feet

18. Foot Care • Elderly with DM high risk for infection, cellulitis, ulcers, gangrene and amputation • Cohort study of patients over 10 years, average age 75, from Archives Int Med, 2007: • 19% DM group had episode of gangrene • 3% DM group had amputation

19. Cardiovascular Risk • Challenges: • Most older patients with DM will die of CV disease • Treatment-Risk Paradox • Older patients have high risk of CV disease • Even small potential decrease in risk of disease could have big benefit and be work risk of treatment • No evidence to suggest that control of diabetes results in less CV risk

20. CV Disease: Modification of Risk Factors • Evidence that older patients with DM and CVD and hyperlipidemia benefit from treatment with statins (similar to/better than younger population) • Recent studies also showing no additional benefit to “tight” control

21. CV Disease: Modification of Risk Factors • Evidence from multiple large studies (SHEP, Syst-Eur) that older patients with Systolic Hypertension benefit from treatment • Decrease stroke • Decrease CHF • HYVET: • Patients over age 80 benefit with decrease stroke, CHF, and mortality

22. Hypertension in Older Patients • Keys from studies: • Treated Systolic Hypertension • Target SBP 150 • Followed standing blood pressures • Benefit seen even though significant number of patients did not even reach target SBP of 150 • Take Home: Moderate SBP reduction in the very elderly can have significant benefit!

23. Complications: Geriatric Syndromes • Older patients with DM also more likely to have: • Falls • Sarcopenia/muscle wasting • Malnutrition • Depression • Dementia • Urinary Incontinence

24. Diabetes in the Frail • More modest goals in BP and glucose control • Balance quality if life • Observe for other risks • Ulcers (heel and sacral) • Malnutrition • dehydration

25. Obesity • Modest overweight (BMI 25-30) associated with LESS mortality in older people • Likely association with increased mortality when BMI over 30 • Conflicting studies with association between weight loss and increased mortality

26. Obesity • BMI does not perform well in older patients (increased body fat for same weight as we age) • Waist circumference has greater prognostic value than BMI in older patients • Weight loss can be associated with loss of muscle and risk of malnutrition in older patients • Almost impossible to tease apart possible underlying disease and weight loss in patients over age 70

27. Dietary Restrictions • No evidence to suggest dietary restrictions in frail elders • Balance other concerns: • Quality of life • Malnutrition • Vitamin deficiencies (D) • Risk of fracture • Depression • Chewing/dental problems

28. Treatment • Treatment options usually similar, balance co-morbidities, frailty, and life expectancy • Target systolic hypertension and hyperlipidemia • No evidence to suggest “tight” control • Modest treatment does have benefit at CV risk reduction in older patients: do not avoid treatment based upon age!! • No evidence to suggest tight control of DM • Goal Hgb A1C 7-8% suggested • Recent ACCORD data supports this

29. Treatment • Must take into account functional status and caregiver/facility status • Consideration of insulin and glucose monitoring • ?caregiver help if needed • Vision • Arthritis of hands • Cognitive status • Treatment in some cases easier in nursing care facility • Do not avoid treatment in functional, independent patients or in those with needed support

30. Take Home Points • Older patients with DM differ in many ways • Treatment of DM relies upon treatment of the individual • Do not avoid treatment in older patients based upon age • Older patients with have higher risk of bad outcomes • Modest treatment benefit significant the high risk • Consider goals of treatment and balance: BP, glucose, weight and lipid reduction goals should be MODEST

31. Questions and Discussion