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Diabetes and The Older Patient

Diabetes and The Older Patient

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Diabetes and The Older Patient

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  1. Diabetes and The Older Patient Debra L. Bynum, MD Division of Geriatric Medicine

  2. Objectives • 1. Review treatment options in caring for older patients with diabetes • 2. Understand risks of hyperglycemia and hypoglycemia in older patients • 3. Appreciate importance of cardiovascular risk reduction in older patients with diabetes by treating hypertension and hyperlipidemia • 4. Gain awareness of association: diabetes, HTN, and vascular risk factors with dementia • 5. Discuss the Treatment-Risk Paradox and how this applies to medical management in older patients

  3. Outline • Prevalence • Acute complications • Treatment options and goals • Risks of longstanding diabetes • Reducing cardiovascular events: treating hypertension and dyslipidemia • Dementia: association with cardiovascular risk factors; ?can we prevent it? • The Treatment-Risk Paradox: Paper review

  4. Cases

  5. Case Study #1 • 78 y/o nursing home resident presents for evaluation of recurrent severe hypoglycemia. Diagnosed age 65 , treated with sulfonylurea without response, subsequently treated with insulin, currently 70/30 14 u in AM, 10 u QHS. Logs: 4-6 readings/day, ranging from 30’s (usually in afternoon or early AM) to mid 500’s, average 195. • PE: 61”, 98 lbs, 138/66, 82. Exam unremarkable A1c=8.6%; Creatinine=1.3, TC=150, HDL=70, LDL=70, TG=50

  6. Case 1: • Does this patient have type 1 diabetes?

  7. Case study #2 • 92 year old woman comes to you on glyburide at 10 mg a day. She, after much discusssion, is unable to check her own glucose. She is very afraid of having a hypoglycemic reaction as she lives alone. Her Hgb A1C is currently 9.8%. She is otherwise healthy, on no other medications, and is completely active and independent.

  8. Case # 2 • What is the goal of treatment in this woman? • What are the risks and the benefits of “tight” control for this patient? • What should her goal A1C be? • Describe some barriers to self monitoring for older patients. • Is Metformin contraindicated?

  9. Case # 3 • You are following a 75 year old woman in the nursing home who has a severe dementia that is probably mixed alzheimers/vascular type, complicated by diabetes, hypertension and hyperlipidemia. • PE: weight 95 lbs

  10. Case # 3… • How tight should control be for this patient? What would be an optimal HgbA1C? • How should her diet be managed? Is there any evidence for dietary restrictions in this setting? • What are the risks and benefits of optimizing her blood pressure control?

  11. Case # 4 • A healthy, active, independent 85 year old woman with DM presents to you for care. She is concerned because her sister has a severe dementia. Other than a blood pressure of 170/70, her PE is unremarkable.

  12. Case study 4 • Is her risk of dementia higher with an underlying diagnosis of diabetes? • What is the significance of isolated systolic hypertension in the elderly? Should this be treated? • What is the average life expectancy of a healthy 80 –85 year old woman?

  13. Some Numbers… • Aging of America • Average life expectancy 72-79 • At age 65, average life expectancy 82! • At age 85, average life expectancy 90 • Fasting growing segment: over 85 • 1.5% population • Almost 5% of population by 2050 • Prevalence of Diabetes • Prevalence of Cardiovascular disease • Prevalence of Dementia

  14. Some Numbers… • Aging of America • Prevalence of Diabetes • Over 20% those over 65 (NHANES 1994) • Framingham Data: Diabetes or impaired glucose tolerance (fasting glucose 120-139) in nearly 40% those over 65 • Over 65 account for over 40% diabetic population • Prevalence of Cardiovascular Disease • Prevalence of Dementia

  15. Some Numbers… • Aging of America • Prevalence of Diabetes • Prevalence of Cardiovascular Disease • Heart disease and stroke: Leading causes of death • 60% deaths in those over 85 due to CVD • Morbidity: stroke and CHF • CHF: 6% new diagnoses/per year in age over 85 • Prevalence of Dementia

  16. Some Numbers… • Aging of America • Prevalence of Diabetes • Prevalence of Cardiovascular Disease • Prevalence of Dementia • 6-10% those over 65 • 30-50% those over 85 • Nearly 70% in those over 95 • By 2025, expected 2 million centenarians in US! • Leading public health concern as the new chronic disease…

  17. Why does Diabetes increase with Age? • Changes in insulin secretion, action and hepatic glucose production with aging • Genetic predisposition • Medications that may change glucose metabolism (?thiazides?) • Older patients more likely to be “lean” diabetics: more problem with insulin secretion than insulin sensitivity as seen in obese, middle aged diabetics • Latent Autoimmune Diabetes of Adults: LADA

  18. What are the risks of Diabetes in the older patient? • Number 1: Cardiovascular disease • Nephropathy • Increasing importance of ESRD in older patients • Neuropathy • Retinopathy • Problems with Feet • New directions: • Dementia • Marker of bad outcomes • Hyperglycemia bad predictor in those admitted with stroke and other acute illnesses

  19. Diagnosis of Diabetes • ADA criteria are NOT adjusted for age • FPG >= 126 • Impaired Glucose Tolerance: glucose 100-125

  20. Impaired Glucose Tolerance… • Occurs in 25% of older patients • Increases risk for development of diabetes • Longitudinal study of older patients: those with Impaired Fasting Glucose had slightly increased risk of cognitive impairment and dementia compared to those with normal glucose • Lifestyle modification can decrease risk of developing diabetes

  21. Short Term Complications • Hyperglycemia • Hypoglycemia

  22. Hyperglycemia • Dehydration • Increased risk in elderly: decreased intake, decreased thirst mechanism • Falls, confusion • Visual disturbances • Significant hyperglycemia distorts lens, visual blurring • Confusion

  23. Nonketotic Hyperglycemic Hyperosmolar Coma • More common than DKA in older patients • Higher mortality • Usually associated with severe dehydration, infection, myocardial event, stroke, acute stress • Precipitating factors: dementia, decreased access to fluid, decreased thirst mechanism

  24. Hypoglycemia • Risk factors: • Older patients • Renal insufficiency • “normal” creatinine means less: glomerular filtration rate is NOT normal in 90 year old woman who weighs 85 lbs with creatinine of 1.1 • Long acting oral agents • Especially in those with renal insufficiency • Poor nutrition • Decreased muscle mass and poor glycemic reserves • Alcohol use • CHF • Post hospitalization • Polypharmacy

  25. Pearl • Calculate GFR in older patients: “normal” creatinine may NOT be normal!!!

  26. Treatment Options • Individualized • Weigh risks of hyperglycemia with hypoglycemia • No data that tight control prevents stroke or cardiovascular events or improves mortality in this age group • Consider cost of medications, limited coverage • Risk of “polypharmacy”, increased risk of side effects and drug-drug interactions • Treatment must be practical: are there functional limitations that will make plan of care difficult

  27. Treatment Options: Some Comments…. Treatment options overall similar in older patients Special notes: beware renal function beware polypharmacy and risk of drug interactions beware risk of interactions with other comorbidities (CHF, dementia)

  28. Treatment Options: Most common… • Sulfonylureas • Stimulation of insulin secretion • Increased risk of hypoglycemia in elderly, esp with renal insuff • Less risk: glipizide (glucotrol), glimepride (amaryl); • Higher Risk: glyburide (diabeta, micronase)

  29. metformin • Biguanide • Decrease hepatic glucose production • Low risk for hypoglycemia • Side effects: gi • Risk: lactic acidosis • Not in women with creat over 1.4, men over 1.5, OR creat clearance < 60 • NOT absolute contraindication with age, but beware of renal function

  30. Thiazolidinediones • Improving insulin sensitivity • Rosiglitazone (avandia) • Pioglitazone (actos) • Do not cause hypoglycemia • Weight gain, fluid retention • Contraindicated with severe heart failure

  31. Insulin • May be best option • Can the patient do it? • Dementia • Caregiver • Vision • Arthritis • Likely underutilized due to fear of hypoglycemia…

  32. Glargine (lantus) insulin • Long acting • Often fear of hypoglycemia because long acting, especially in patients with renal insufficiency or unreliable po intake • But studies demonstrating less risk of hypoglycemia, especially in patients with “brittle” diabetes and nocturnal hypoglycemia

  33. Treatment Goals • Individualized • No data for tight control… • Most recommend Hgb A1c 7-8% • Other options: • Tight control: healthy “young” older patients (lifespan 20years) to decrease risk nephropathy, retinopathy • “permissive”: those with advanced illnesses, terminal illnesses; goal more to prevent severe hyperglycemia and avoid hypoglycemia; goal glucoses 200 range

  34. Treatment Goals • Endocrinology, General Internal Medicine/Family Medicine or Geriatrics? • Geriatricians see older patients with dementia; Endocrinologists use more complicated regimens and care for slightly younger patients and/or those with microvascular complications • ALL have lower than advised rates of screening for diabetic complications, adequate treatment of hypertension and hyperlipidemia, and goal AIc– • is this bad? Don’t know….

  35. Some special circumstances • Tube feeding • Increases hyperglycemia • Specialized formulas • Acute setting: continuous insulin, BID NPH, Q6 Reg • Long term: basal insulin with glargine; with bolus feeds, consider short acting insulin prior to bolus

  36. Special Circumstances… • Type 1 diabetes • Decreased beta cell function with aging • More common in younger patients but can occur in older patients (10-15% of elderly patients with diabetes have evidence of autoimmunity) • “latent autoimmune diabetes of adulthood” • DKA • “brittle” with episodes of hypoglycemia • First case…

  37. Nursing home setting • Risk of ulcers (heel and sacral) • Risk of dehydration • Little to support dietary restrictions in frail nursing home elders • Quality of life concerns • Risk of malnutrition • Anorexia/depression • Chewing/dental problems • 2001 study found no difference in glycemic control in patients on restricted diet compared to those on regular diet with more emphasis on pharmacologic control

  38. Nephropathy • Previously no recommendation to screen for microalbuminuria if normal renal function • Lower risk of ESRD in older patients with DM • Long interval between presence of albumin and ESRD…. • Current AGS and ADA guidelines recommend annual check for microalbumin • Lifespan of 70 year old is 10 years or more • ESRD increasing prevalence in elderly with more older patients on dialysis… • Marker of increased stroke and CVD risk in addition to nephropathy in older patients

  39. Vision… • Retinopathy • Prevalence in older patients with DM seems to be less and overall less progressive disease than in younger patients with DM • Glaucoma • Three times more common in older patients with diabetes (11% vs 3.8%) • Cataracts • More common in older patients with DM (38% vs 16%) • Association with more rapidly progressive posterior capsule cataracts …

  40. Neuropathy • Very common • Over 50% in those over 80 • Not always due to Diabetes • 1/3 older patients cannot see/reach feet • Importance of caregiver education

  41. Special Population: The FRAIL • Not all older patients are FRAIL • Frailty as increasingly recognized diagnosis • Features: • Functional decline • Sarcopenia • Weight loss • Associated diseases such as Diabetes • Stressors that precipitate • Hip fractures, pneumonia, depression, stroke

  42. Treatment of the Frail • Care with any dietary restrictions • Significant number nursing home residents with weight loss, at risk for malnutrition • Tight control likely not goal • Still consider treatment of cardiovascular risk factors to reduce risk of CHF, stroke and morbidity

  43. Big Goal: Prevention of Cardiovascular Events… • Common diseases: Diabetes, Hypertension, Hyperlipidemia • Common outcomes: Stroke, CHF/CAD, Dementia • No evidence that aggressive treatment of DM prevents/ changes these outcomes, but DM often seen in patients with HTN and hyperlipidemia, and mounting evidence that treatment of these risk factors can modify the risk of CAD, CHF, stroke and possibly even dementia in this group

  44. Diabetes: CV equivalent • Patients with type 2 diabetes without prior hx of heart attack have same risk of MI compared to patients with prior hx of MI • Therefore, treat patients with DM as aggressively as secondary treatment in patients with known CVD • ?age as new “CV equivalent” • Bad combination: DM and older age!!!

  45. Hypertension and Hyperlipidemia • Treatment of hypertension and hyperlipidemia reduces CV outcomes • Biggest bang for the buck: treating in High Risk Groups • Higher benefits in those with diabetes and advanced age

  46. Hypertension • Hypertension is very common in older patients, mainly due to Systolic Hypertension (SH) • Hypertension seen in 60% those over 65 • 75% hypertension in older patients =SH • JNC definition: SBP >160, DBP <90 • Pulse Pressure: SBP – DBP • Higher (over 50) due to stiff arteries • SBP and PP MORE predictive of stroke and CV events in older patients

  47. Hypertension • Multiple large randomized controlled trials have demonstrated significant benefit in treating Systolic Hypertension in older patients • SHEP • SYST-EUR • SYST-CHINA • SCOPE

  48. Systolic Hypertension • Treatment of SH in older patients: • Decreased risk of stroke • Decreased risk of CHF • Decreased combined endpoint of all CV events (CHF, stroke, CAD, mortality) • Larger benefits seen in patients with diabetes…

  49. Treatment of Hypertension • Choice of agents: • Thiazide diuretics (HCTZ, maxzide) ALLHAT study: JUST AS EFFECTIVE AS THE MORE EXPENSIVE, NEWER MEDICATIONS! • ACE inhibitors, angiotensin II receptor blockers, long acting calcium channel blockers • Beta blockers

  50. Systolic Hypertension and Dementia… • Epidemiological studies :association between SH and dementia in older patients • Surprise finding in SH trials • Patients in treatment arms of trials had reduced risk of dementia at follow up (4 years) compared to those in placebo group • Two surprises: • Those in placebo group, even after trial ended and started on antihypertensive treatment, STILL had increased risk of dementia • Risk of Vascular AND Alzheimer dementias were increased!