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THE AMERICAN GERIATRICS SOCIETY Geriatrics Health Professionals.

DIABETES IN THE OLDER PATIENT Debra Bynum, MD Associate Professor of Medicine Division of Geriatric Medicine University of North Carolina. AGS. THE AMERICAN GERIATRICS SOCIETY Geriatrics Health Professionals. Leading change. Improving care for older adults. True or False?.

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THE AMERICAN GERIATRICS SOCIETY Geriatrics Health Professionals.

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  1. DIABETES IN THE OLDER PATIENTDebra Bynum, MDAssociate Professor of MedicineDivision of Geriatric MedicineUniversity of North Carolina AGS THE AMERICAN GERIATRICS SOCIETY Geriatrics Health Professionals. Leading change. Improving care for older adults.

  2. True or False? 1. A healthy 90-year-old woman is likely to live to be 95. 2. Benzodiazepines are the most common cause of emergency hospitalizations for adverse drug events in older adults. 3. Patients over the age of 80 should not be treated for systolic hypertension, because of an increased risk of falls. 4. Compared with younger adults, older adults at risk of DM have greater benefit from lifestyle modification in preventing the development of DM.

  3. Outline • Prevalence • Heterogeneity (Patients and Disease) • Specific Complications • Diabetes and Geriatric Syndromes • Diabetes in the Frail • Treatment Basics • Take-Home Points

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

  5. Take-Home Points • Older adults with DM are heterogeneous in many ways • Treatment of DM relies on treatment of the individual • Do not avoid treatment in older patients based on age • Older patients have higher risk of bad outcomes • Modest treatment benefit is significant in high-risk populations • But balance risks of treatment and goals of care in patients with frailty or limited life expectancy • Evidence suggests modest treatment goals (vs. tight control) are associated with best outcomes

  6. Prevalence • Majority of patients with DM are over age 60 • 20%–30% of patients over age 65 have DM • Many over age 60 may have undiagnosed DM • CDC estimate: DM (diagnosed and undiagnosed) affects 23% of people over 60 • Framingham data: 40% of those over 65 have DM or impaired fasting glucose

  7. Increasing prevalence • Increasing overall prevalence of type 2 DM with increasing age of US population and increasing obesity • Prevalence in long-term-care facilities: increased from 16% in 1995 to over 20% in 2004

  8. Heterogeneity: Patients • Average life expectancy 72–79 years • At age 65, average life expectancy is to 82 • At age 85, average life expectancy is to 90 • Fastest growing population: over 85 • Differences: • Age (65, 75, 85, 95, 100) • Frailty and age are not equal • Associated comorbidities

  9. 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 long-standing type 1 diabetes

  10. Complications • Hyperglycemia • Hypoglycemia • Nephropathy • Visual loss • Infection/amputation • Cardiovascular disease • Increased risk of geriatric syndromes

  11. Hyperglycemia • Dehydration • Increased risk in elderly • Decreased oral intake, decreased thirst mechanism • Visual disturbance • Confusion • Increased urinary incontinence • Increased risk of falls

  12. Non-ketotic 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, and higher mortality • Older patients with dementia, decreased access to free water (nursing care setting), and decreased thirst are at higher risk

  13. hypoglycemia (1 of 3) Risk factors: • Older age • Renal insufficiency • Long-acting oral agents (sulfonylureas) • Poor nutrition • Alcohol use • CHF • Post-hospitalization / frequent hospitalizations • Polypharmacy

  14. hypoglycemia (2 of 3) • Risk 2%–9% in cohort studies • Those over 75: double the rate of ED visits for hypoglycemia compared with younger patients • Associated with later development of dementia? • Cohort study of patients followed for over 20 years1 • Patients with at least one episode of severe hypoglycemia had increased risk of development of diabetes • May be confounder and not causal • See also CDC: Diabetes public health resource, 2012 (www.cdc.gov/diabetes) • 1. Whitmer RA, et al. JAMA. 2009;301:1565-1575.

  15. hypoglycemia (3 of 3) Risks of hypoglycemia: • Falls and fracture • Confusion and dizziness (more common than sweating and shaking in older patients) • Hospitalizations • Increased risk of CV events?

  16. Emergency Hospitalizations for Adverse Drug Events • Nearly 100,000 emergency hospitalizations for ADEs in people over age 65 in the US each year • Almost half of hospitalizations in those over age 80 • Majority are NOT due to notorious “high-risk” medications, but due to commonly used medications with proven benefit in older patients! • Warfarin ― 33.3 % • Insulins ― 13.9% • Oral antiplatelets ― 13.3 % • Oral hypoglycemics ― 10.7% Budnitz DS, et al. N Engl J Med. 2011;365:2002-2012.

  17. Nephropathy • Overall, increases 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

  18. Renal Insufficiency “Normal creatinine” may not be normal • Calculate GFR • GFR depends on age, weight, sex • Creatinine of 1.1 in a 98-pound woman is not “normal”

  19. VISION Loss • Often multifactorial • Retinopathy often less progressive than in younger patients with DM • Glaucoma 3 times more common in older patients with DM (11% vs. 4%) • Cataracts more common and more rapidly progressive

  20. Foot Care • 1/3 of older patients cannot see/reach feet • Neuropathy is common and not always due to DM in older patients (50% of patients over 80 have peripheral neuropathy) • Elderly with DM are at high risk of infection, cellulitis, ulcers, gangrene, and amputation • 10-year cohort study of patients with average age 751 • 19% of DM group had episode of gangrene • 3% of DM group underwent amputation 1. Bethel MA, et al. Arch Intern Med. 2007;167:921-927.

  21. Cardiovascular Risk Challenges: • Most older patients with DM will die of CVD • Treatment-risk paradox: • Older patients are at high risk of CVD • Even small potential decrease in risk of CVD could have big benefit and be worth the risk of treatment

  22. CVD: Modification ofRisk Factors (1 of 2) • There is evidence that older patients with DM, CVD, hyperlipidemia benefit from treatment with statins (similar to/better than younger population) • Recent studies show no additional benefit of tight control

  23. CVD: Modification ofRisk Factors (2 of 2) • There is evidence from multiple large studies (SHEP, Syst-Eur) that older patients with systolic hypertension benefit from treatment • Decrease stroke • Decrease CHF • HYVET (Hypertension in the Very Elderly) • Patients over age 80 benefit with decreased risk of stroke, CHF, and mortality

  24. Hypertension in Older Patients • Keys from studies: • Treated systolic hypertension • Targeted SBP 150 • Followed standing blood pressures • Benefit seen even though significant number of patients did not reach target SBP of 150 • Take-home point: Moderate SBP reduction in the very elderly can have significant benefit!

  25. Complications:Geriatric Syndromes Older patients with DM are more likely to have: • Falls • Sarcopenia/muscle wasting • Malnutrition • Depression • Dementia • Urinary incontinence

  26. Diabetes in the Frail • More modest goals in BP and glucose control • Balance quality of life • Observe for other risks: • Ulcers (heel and sacral) • Malnutrition • Dehydration

  27. Treatment (1 of 5) • Balance comorbidities, frailty, and life expectancy • Target systolic hypertension and hyperlipidemia • No evidence supports tight control • Modest treatment reduces CV risk in older patients ―do not avoid treatment based on age!! • Relative risk reduction for secondary prevention of CV events in older patients with DM is same as for younger patients • Given higher likelihood of CV events, this translates to potential for greater absolute reduction of CV events

  28. Treatment (2 of 5) No evidence supports tight control of DM • Target HbA1c of 7%–8% is suggested for most older patients • HbA1c of 8%–8.9% is associated with better functional outcomes in community-dwelling,NH-eligible older patients than in those with HbA1c of 7%–8%1 • ACCORD, ADVANCE, and VADT trials: No benefit of tight control, and older patients had higher risk of hypoglycemic complications 1. Yau CK, et al. J Am Geriatr Soc. 2012;60:1215-1221.

  29. Treatment (3 of 5) Must take into account functional status and availability/reliability of caregiver (LTC setting) • Considerations for insulin and glucose monitoring: • Vision • Arthritis of hands • Cognitive status • Do not avoid treatment in functional, independent patients or in those with needed support

  30. Treatment (4 of 5) • Treatment options are similar to those for younger patients • Metformin is an excellent option for many (with good renal function) due to profile and lack of associated hypoglycemia • Avoid long-acting sulfonylureas such as glyburide ― opt for shorter-acting agents such as glipizide • Use pioglitazone with caution ― risk of fluid retention and heart failure is greater in elderly • Don’t avoid insulin (glargine, etc.)

  31. Treatment (5 of 5) • Smoking cessation • Aspirin • Greatest benefit is in patients over age 65 with DM and/or diastolic hypertension, for secondary prevention of known macrovascular disease • Evidence for primary prevention of CV events in patients with DM is still unclear

  32. Diet and Lifestyle (1 of 2) • Medical nutrition therapy (MNT) • RCT in patients over age 65: MNT decreased fasting glucose by almost 20 points and improved HbA1c by 0.5% • Diabetes Prevention Program Study ― Those over 60 compared to younger adults: • Better adherence and meeting attendance • Better response to diet/lifestyle modification • Less, but still some, response to metformin in preventing the development of DM

  33. Diet and Lifestyle (2 of 2) • No evidence supports dietary restrictions in frail elders • Balance other concerns: • Quality of life • Malnutrition • Vitamin deficiencies (vitamin D) • Risk of fracture • Depression • Chewing/dental problems

  34. Take-Home Points • Older adults with DM are heterogeneous in many ways • Treatment of DM relies on treatment of the individual • Do not avoid treatment in older patients based on age • Older patients have higher risk of bad outcomes • Modest treatment benefit is significant in high-risk populations • But balance risks of treatment and goals of care in patients with frailty or limited life expectancy • Evidence suggests modest treatment goals (vs. tight control) are associated with best outcomes

  35. TRUE OR FALSE? 1. A healthy 90-year-old woman is likely to live to be 95. True 2. Benzodiazepines are the most common cause of emergency hospitalizations for adverse drug events in older adults. False 3. Patients over the age of 80 with systolic hypertension should not be treated, because of an increased risk of falls. False 4. Compared with younger adults, older adults at risk for DM have greater benefit from lifestyle modification in preventing the development of DM. True

  36. References (1 of 2) • Araki A, Ito H. Diabetes mellitus and geriatric syndromes. Geriatr Gerontol Int. 2009;9:105-114. • Barnett KN et al. Mortality in people diagnosed with type 2 diabetes at an older age: a systematic review. Age and Ageing. 2006;35:463-468. • Beckett NS et al. Treatment of hypertension in patients 80 years of age or older. N Engl J Med. 2008;358:2887-2898. • Bethel MA, Sloan FA, Belsky D, Feinglos MN. Longitudinal incidence and prevalence of adverse outcomes of diabetes mellitus in elderly patients. Arch Intern Med. 2007;167:921-927. • Budnitz DS et al. Emergency hospitalizations for adverse drug events in older Americans. N Engl J Med. 2011;365:2002-2012. • Cahill M et al. Prevalence of diabetic retinopathy in patients with diabetes mellitus diagnosed after the age of 70 years. Br J Ophthalmol. 1997;81:218-222. • Centers for Disease Control and Prevention. National Diabetes Fact Sheet: General Information and National Estimates on Diabetes in the United States. 2011. • Cernea S, Buzzetti R, Pozzili P. B cell protection and therapy for latent autoimmune diabetes in adults. Diabetes Care. 2009;32:S246-S252. • Cigolle CT, Blaum CS, Halter JB. Diabetes and cardiovascular disease prevention in older adults. Clin Geriatr Med. 2009;25:607-641. • Diabetes Prevention Program Research Group. 10 year follow up of diabetes incidence and weight loss in the Diabetes Prevention Program Outcomes Study. Lancet. 2009;374:1677-1686. • Duckworth W, Abraira C, Moritz T et al for the VADT Investigators. Glucose control and vascular complications in veterans with type 2 diabetes. N Engl J Med. 2009;360:129-139. • Feil DG, Rajan M, Soroka O, Tseng C, Miller DR, Pogach LM. Risk of hypoglycemia in older veterans with dementia and cognitive impairment: implications for practice and policy. J Am Geriatr Soc. 2011;59:2263-2272. • Haas L. Management of diabetes mellitus medications in the nursing home. Drugs Aging. 2005;22:209-218.

  37. References (2 of 2) • Joseph AJ, Friedman EA. Diabetic nephropathy in the elderly. Clin Geriatr Med. 2009;25:373-389. • Kirkman MS et al. Diabetes in older adults: a consensus report. J Am Geriatr Soc. 2012;60:2342-2356. • Knowler WC, Barrett-Connor E, Fowler SE et al for the Diabetes Prevention Program Research Group. Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. N Engl J Med. 2002; 346:393-403. • Kyrou I, Tsigos C. Obesity in the elderly diabetic patient. Diabetes Care. 2009;32:S403-S409. • Miller ME, Bonds DE, Gerstein HC et al for the ACCORD Investigators. The effects of baseline characteristics, glycaemia treatment approach, and glycated haemoglobin concentration on the risk of severe hypoglycaemia: post hoc epidemiological analysis of the ACCORD study. BMJ. 2010;340:b5444. • Patel A, MacMahon S, Chalmers J et al for the ADVANCE Collaborative Group. Intensive blood glucose control and vascular outcomes in patients with type 2 diabetes. N Engl J Med. 2008;358:2560-2572. • Schwartz AV et al. Diabetes related complications, glycemic control, and falls in older adults. Diabetes Care. 2008;31:391-396. • Sinclair AJ, Paolisso G, Castro M et al for the European Diabetes Working Party for Older People. European Diabetes Working Party for Older People 2011 clinical guidelines for type 2 diabetes mellitus: executive summary. Diabetes Metab. 2011;37(suppl3):S27-S38. • Whitmer RA, Karter AJ, Yaffe K. Hypoglycemic episodes and risk of dementia in older patients with type 2 diabetes mellitus. JAMA. 2009;301:1565-1575. • Yau CK et al. Glycosylated Hgb and functional decline in community dwelling, nursing home eligible elderly adults with diabetes mellitus. J Am Geriatr Soc. 2012;60:1215-1221.

  38. Thank you for your time! Visit us at: www.americangeriatrics.org Facebook.com/AmericanGeriatricsSociety Twitter.com/AmerGeriatrics linkedin.com/company/american-geriatrics-society

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