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Belinda Setters, MD, MS, AGSF March 6, 2014 Kentucky Cardiopulmonary Rehab Symposium

Finding the Sweet Spot: DM II treatment in post acute rehabilitation (& a few crumbs for granny – the key to treating DM II in frail elders) . Belinda Setters, MD, MS, AGSF March 6, 2014 Kentucky Cardiopulmonary Rehab Symposium. The Sweet Spot: DM II treatment update. Disclosures

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Belinda Setters, MD, MS, AGSF March 6, 2014 Kentucky Cardiopulmonary Rehab Symposium

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  1. Finding the Sweet Spot:DM II treatment in post acute rehabilitation (& a few crumbs for granny – the key to treating DM II in frail elders) Belinda Setters, MD, MS, AGSF March 6, 2014 Kentucky Cardiopulmonary Rehab Symposium

  2. The Sweet Spot: DM II treatment update Disclosures • Acting Associate Chief of Staff , Geriatrics & Extended Care • Director, Acute Care for Elders & Transitional Care Programs Robley Rex VAMC, Louisville, Ky • Associate Clinical Professor University of Louisville Depts. of Internal and Family & Geriatric Medicine No financial (or other) incentives, stock or compensation

  3. The Sweet Spot: DM II treatment update Learning Objectives • Review updated guidelines for DM II treatment • Identify pitfalls of treatment in post acute (rehabilitation) care • Understand unique features of elderly patients that complicate treatment • Understand the importance of individualized care

  4. The Sweet Spot: DM II treatment update • Just the stats m’am. . . • 25.8 million diabetics (all ages) = 8.3% of population • > 65 yo, increases to 27% of population (10.9 million) • 7 million undx patients • DM II associated with 2 x higher disability • 42% of persons > 65 yo have at least one disability • = 14 million people American Diabetes Association: www.diabetes.org CDC: www.cdc.org/diabetes NIH: www.ndep.nih.gov/diabetes-facts

  5. The Sweet Spot: DM II treatment update

  6. The Sweet Spot: DM II treatment update From Dr. Samuel E. Dagogo-Jack: http://www.medscape.org/viewarticle/536351

  7. The Sweet Spot: DM II treatment update

  8. The Sweet Spot: DM II treatment update

  9. The Sweet Spot: DM II treatment update • Treatment goals . . . • Fasting blood glucose < 140 mg • Hemoglobin A1C < 7 • If can push to get better #s, without side effects (hypoglycemia), then ok to do so in adult patients • Post acute care (“rehabilitation”) guidelines follow those of non-critical care acute recommendations J ClinEndocrinolMetab2012, 97(1):16-38

  10. The Sweet Spot: DM II treatment update • Treatment goals . . . Short term concerns • Minimize adverse effects of high glucose • Wound healing & infection • Confusion/MS change • Fatigue = decr. participation in therapy • Falls • Minimize HYPOglycemia • Minimize “pill burden” • Transition patient to home

  11. The Sweet Spot: DM II treatment update • Treatment goals . . . Options. ( + ) ( --) d/c monitoring

  12. The Sweet Spot: DM II treatment update • Recommended therapy: Insulin Long Acting Insulin (Daily) Short Acting Insulin (with Meals) OR Intermediate acting (Twice Daily)

  13. The Sweet Spot: DM II treatment update • Insulin types

  14. The Sweet Spot: DM II treatment update • Insulin types . . . . . “the slide” • Sliding Scale Insulin • Good for short term coverage to adjust long acting insulins • Should not be used as a substitute for long acting or short/regular insulin regimen. diabetesmanager.pbworks.com

  15. The Sweet Spot: DM II treatment update

  16. The Sweet Spot: DM II treatment update • Oral agents www.medscape.org

  17. The Sweet Spot: DM II treatment update • Nutrition therapy Rec: “Consistent Carb” diet + Education & Accountability • Exercise Therapy, activities, walking American Diabetes Association: www.communitydiabetes.org

  18. The Sweet Spot: DM II treatment update • Control Vascular Risk Factors • Tobacco cessation • Nutrition • Weight Loss • HTN management • HLD management / statins • Anti-inflammatory therapies • Mental & physical activity

  19. The Sweet Spot: DM II in elders • Treatment Considerations (CHF/AGS, presented at AGS Symposium, May 2003)

  20. The Sweet Spot: DM II in elders

  21. The Sweet Spot: DM II treatment update • DM in The Elderly: Unique Concerns • Erratic eating (or dependency on being fed) • Inability to report symptoms (dementia, vague symptoms) • Polypharmacy: multiple meds – competition for clearance • Slowed metabolism / impaired clearance • Shift in water-fat body content • Low reserve, can’t respond to hypoglycemia Med Care 2006 Apr;44(4):373-7JAMA 2006 Oct 18;296(15):1858-66. J Am CollCardiol2009 Jan 20;53(3):298-304

  22. The Sweet Spot: DM II treatment updates • DM in Elders: Frailty • Loss of functional reserve • Slowed response to stress / pathologic illness • Multisystem organ involvement • Estimated prognosis (life expectancy)1-2 years Lancet 2013; 381(9868): 752-762. JAGS 2006; 54(6): 991-100. ClinGeriatrMed 2011; 27(1): 1-15.

  23. The Sweet Spot: DM II treatment updates • DM in Elders: Frailty Philosophy, Ethics, and Humanities in Medicine 2009 4:3   doi:10.1186/1747-5341-4-3

  24. The Sweet Spot: DM II in elders • Treatment Considerations • Hemoglobin A1C < 7 • Mean plasma glucose 154 mg/dl (2-3 months) • Healthy adults with > 10 year life expectancy • Hemoglobin A1C between 7 – 8.5 • Mean plasma glucose 180 mg/dl (2-3 months) • Adults with limited life expectancy, history of severe hypoglycemia, or advanced micro-vascular or macro-vascular disease DIABETES CARE, 2013; 36(1): S11-S66

  25. The Sweet Spot: DM II in elders • Treatment Considerations • Blood Pressure & Lipid Goals • Blood pressure < 140/80 • LDL < 100 mg/dl or 70 with CVD • HDL > 40 mg/dl • Triglycerides < 150 mg/dl DIABETES CARE, 2013; 36(1): S11-S66

  26. The Sweet Spot: DM II in elders • The “Sweet Spot” for Frail Elders J Am Geriatr Soc 60:1215–1221, 2012.

  27. The Sweet Spot: DM II in elders • Other thoughts: Hypoglycemia • 2 episodes = 80% increased risk for Dementia development • 3 episodes = 94% increased risk for dementia development

  28. The Sweet Spot: DM II in elders • Other thoughts • Life Expectancy • Changes w/ comorbidity • Changes w/ frailty • Goals of Care • Pt Preferences

  29. The Sweet Spot: DM II treatment update • Wrap up • Blood glucose < 140 or Hg A1C < 7 • Control vascular, other risk factors • Consider QOL, pt preferences/GOC & life expectancy • For most elders, especially frail elders, A1C = 8 is target 8 at 80 honey!

  30. Belinda.Setters@va.govGeriatrics & Extended Care http://vaww.louisville.va.gov/ @BelindaSetters502-287-5995

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