Treatment of diabetes mellitus in the elderly

1. Treatment of diabetes mellitus in the elderly October 2008 Shmuel (Boris) Levit M.D. Ph.D.

2. Case 1 82- year- old woman . Suffers from diabetes for last 22 years. Her weight 79 kg; height 159 cm ; BMI= 31.2.She complaints of fatigue , weakness; palpitations on minimal physical effort. Pains in her feet. She is constantly treated with : • Glucophage 850 mg x 3/ day • Gluben 5 mg x 3/day • Tritace 5 mg x 1/ day • Normiten 50 mg/ day • Norvasc 5 mg/ day • Aspirin 100 mg/day • Lipitor 20 mg/ day • In spite of the above treatment her HBA1C levels are 7.8-8.6% for last 10 months. Her lipids are at the target range and her creatinine 1.4 mg/dl. Her electrolytes are normal. CBC is normal . HB = 13.5 g/dl . Microalbumin = 78 mg/day ( urine) • Fundus: no evidence of retinopathy

3. Case 1 ( cont’d) • Her cognitive status is satisfactory. She functions well. • Physical activity: walks 40 min per day. • From her past : IHD; s/p multiple coronarographias . Mild CHF. • Hypertension; Hyperlipidemia; Obesity. • D. Nephropathy; Mild polyneuropathy. • Three months ago her family doctor added 4 mg of Avandia per day.

4. Now she is coming to visit you • Her lab. Tests show : Mild anemia HB= 11.6 G/dl • Creatinine =1.45 mg/dl • HBa1C = 7.9% • Liver enzymes elevation : 20% above upper normal limit . • She complaints of exacerbation of palpitations on effort. • Physical exam.: Obesity; Lungs are clear; Heart- mild tachycardia of 92 /min; BP 135/80. • Leg edema ++. Mild hepatomegaly . • She gained 5 kg and now her weight is 84 kg.

5. Question N 1 Whether our patient’s diabetes is well – controlled ?

6. Question N 2 • Would you suggest any changes in her treatment ?

7. The prevalence of diabetes continues to increase steadily • 1.4 percent between the ages 25 of 44 years • to 3.6 percent between the ages of 45 and 54 years, • 7.8percent between the ages of 55 and 64 years, • Over 10 percent over the age of 65 years • Over 20 percent among frail elderly people living in nursing homes • There are probably similar numbers of undiagnosed patients at all ages.

8. Elderly patients characteristics • Higher risk for polypharmacy • Functional disabilities • Cognitive impairment • Depression • Urinary incontinence • Falls and persistent pain

9. Goals of diabetes management in older adults • Similar to those in younger adults • Management of both hyperglycemia and risk factors. • Avoidance of hypoglycemia, • Hypotension and drug interactions due to polypharmacy are of major concern. • Management of coexisting medical conditions is important as it influences their ability to perform self-management.

10. Glycemic goals – middle ground • Hyperglycemiaincreases dehydration, impairs vision and cognition , all of which contribute to functional decline and an increased risk of falling in elderly diabetic patients. • On the other hand, side effects of diabetes treatment, most notably hypoglycemia, can result in poor outcomes, such as traumatic falls and exacerbation of co-morbid conditions.

11. Goals for glycemic controls • Should be based upon the individual's overall health. • The appropriate target for hemoglobin A1C (HbA1c) in fit elderly patients who have a life expectancy of over five years, should be 7.0 to 8.0 percent. • The goal may be somewhat higher in those whose life expectancy is less or in those with multiple medical and functional co-morbidities.

12. Nutrition  • The elderly are as much at risk for under-nutrition as for obesity. • As an example, in a group of diabetic nursing home residents with a mean age of 81 years, 21 percent weighed <80 percent of average body weight for age A less restricted diet can often improve quality of life with little or no adverse effect upon glycemic control • Weight loss increases the risk of morbidity and mortality in older adults.

14. Drug therapy

15. SulfonylureaDrug-induced hypoglycemia is most likely to occur • After exercise or missed meals • When patients eat poorly or abuse alcohol • When patients have impaired renal or cardiac function or intercurrent gastrointestinal disease • During therapy with salicylates, sulfonamides, fibric acid derivatives (such as gemfibrozil), and warfarin. • After being in the hospital

16. Metformin  • Should be given with caution because of the risk of lactic acidosis. • Elderly patients often have impaired renal function despite an apparently normal serum creatinine concentration. • Increased risk for developing other conditions that reduce renal function further or cause lactic acidosis (myocardial infarction, stroke, cardiac failure, pneumonia). • Weight loss and gastrointestinal side effects may also be limiting factors

17. Patients should be cautioned to stop taking Metformin immediately if they become ill for any reason, or if they are to undergo a procedure requiring the use of iodinated contrast material.

18. Thiazolidinediones • May be useful for some older diabetic patients because they can be given to patients who have impaired renal function. • They are well tolerated in older adults and do not cause hypoglycemia. • However, limited experience, high cost, and concerns regarding fluid retention, congestive heart failure, MI, and fractures may limit their usefulness.

19. Alpha-glucosidase inhibitors • Have not been widely tested in elderly diabetic patients • Are likely to be fairly safe and effective. • The main side effects which limit their use are flatulence and diarrhea, which are common

20. DPP-IV inhibitors • DPP-IV inhibitors have no risk of hypoglycemia and are weight-neutral, • May be attractive agents to use in the elderly. • However, the long-term safety with this class of drug has not been established, and the drugs have been tested in relatively small numbers of patients in clinical trials • The dose of sitagliptin should be adjusted in patients with renal insufficiency.

21. GLP-I therapies • There is no risk of hypoglycemia with the use of exenatide alone. • However, the need for twice daily subcutaneous injections makes it difficult to use in the elderly population.

22. Insulin •  Insulin is sometimes underutilized in the elderly because of fear (by the physician, patient, or family) that it is too complicated or dangerous. • With the availability of long acting insulins, it has become easier to add once daily insulin to oral hypoglycemic medications in older patients • Patients may wrongly assume that their symptoms of fatigue are due to "old age" rather than hyperglycemia. However, in many older patients quality of life improves substantially when they take one or two daily doses of intermediate- or long-acting insulin. • Patient should be physically and cognitively capable of drawing up and giving the appropriate dose of insulin, monitoring blood glucose, and recognizing and treating hypoglycemia. • Insulin metabolism is altered in patients with chronic renal failure, so that less insulin is needed when the glomerular filtration rate is below 50 mL/min.

23. COMMON GERIATRIC SYNDROMES ASSOCIATED WITH DIABETES

24. Cognitive impairment •  Diabetes is associated with increased risk of dementia. Many older patients with dementia remain undiagnosed, particularly in the early stages. Elderly patients with diabetes and cognitive dysfunction may have difficulty performing self-management and following complicated treatment regimens. Cognitive function should be assessed in elderly diabetic patients when there is: • Nonadherence with therapy. • Frequent episodes of hypoglycemia. • Deterioration of glycemic control occurs without obvious explanation.

25. Depression •   Depression occurs at a higher rate in older patients with diabetes compared with age-matched controls . • Depression is frequently undiagnosed and remains untreated in this high risk population . • Depression has been associated with poor glycemic control and with accelerated rates of coronary heart disease in diabetic patients . • Early identification with a short screening tool (such as a geriatric depression scale) and treatment may help achieve better glycemic control

26. Polypharmacy •  Use of multiple drugs is common in older adults. • Management of hyperglycemia and its associated risk factors often increases the number of medications even more in the elderly with diabetes. • Side effects may exacerbate co-morbidities and impede the patient's ability to manage his/her diabetes. • Therefore, the medication list should be kept current and reviewed at each visit

27. Falls •  The increased risk of falls in older adults with diabetes is multifactorial. • Presence of peripheral and/or autonomic neuropathy, reduced renal function, muscle weakness, functional disability, loss of vision, polypharmacy, co-morbidities like osteoarthritis and even mild hypoglycemia may contribute to falls in frail older adults. • While good glycemic control prevents progression of some diabetes complications and therefore may decrease the risk of falls, hypoglycemia that occurs as a result of intensive glycemic control may increase the risk of falls.. • Nevertheless, the benefits of improved glycemic control to reduce diabetes-related complications (and decrease risk of falls) must be balanced with the possible increased risk of falls with intensive insulin therapy. These findings support the use of less rigorous glycemic goals (A1C 7 to 8 percent) in the elderly.

28. Urinary incontinence •  Diabetes increases a woman's risk of developing urinary incontinence. • Risk factors : urinary tract infection, vaginal infection, autonomic neuropathy (resulting in either neurogenic bladder or fecal impaction) and polyuria due to hyperglycemia. • Although there is no direct evidence to suggest deleterious effect of incontinence on diabetes control, identification and treatment are recommended to improve quality of life in women.

29. Nursing home patients •   There are few studies and guidelines directed at care of older adults with diabetes residing in nursing homes. Life expectancy, quality of life, severe functional disabilities and other co-existing conditions mentioned above affect goal setting and management plans. • Exercise continues to be important for all patients. • Regular diet without concentrated sweets may improve quality of life and prevent weight loss. • Treatment regimens should be chosen to achieve maximal glycemic control possible, with a focus on avoidance of hypoglycemia and control of hyperglycemic symptoms.

30. SCREENING FOR MICROVASCULAR COMPLICATIONS

31. Retinopathy • Regular eye examinations are extremely important for elderly diabetic patients because poor vision can lead to social isolation, an increased risk of accidents, and impaired ability to measure blood glucose and draw up insulin doses. • A complete ophthalmologic examination should be performed by a qualified ophthalmologist or optometrist at the time of diagnosis and at least yearly thereafter. • The purpose is to screen not only for diabetic retinopathy but also for cataracts and glaucoma, which are more common in elderly diabetic compared with nondiabetic subjects. • Cataracts are over twice as common in people over age 65 years with diabetes compared with normal subjects , while glaucoma is almost three times more common.

32. Nephropathy •   The availability of seemingly effective therapy for diabetic nephropathy with ACE- inhibitors has led to the suggestion that all patients with diabetes be screened for microalbuminuria. • However, in older adults, the presence of albuminuria in elderly patients with type 2 diabetes is often not due to diabetic nephropathy, and therefore other conditions should be ruled out

33. Foot problems • Both vascular and neurologic disease contribute to foot lesions. • The prevalence of diabetic neuropathy in patients with type 2 diabetes is 32 percent overall and more than 50 percent in patients over age 60 years . • More than 30 percent of older diabetic patients cannot see or reach their feet, and may therefore be unable to perform routine foot inspections. • We recommend that elderly diabetic patients have their feet examined at every visit; • Visits to a podiatrist on a regular basis should also be considered. • A detailed neurologic examination and assessment for peripheral vascular disease should be performed at least yearly.

34. CARDIOVASCULAR RISK REDUCTION •  Both diabetes and age are major risk factors for coronary heart disease. • Risk reduction should be focused upon the following areas: • Smoking cessation • Treatment of hypertension • Treatment of dyslipidemia • Aspirin therapy • Exercise

35. Goal blood pressure •   Recommended general goals for the treatment of hypertension in the elderly are as follows : • A diastolic pressure of 85 to 90 mmHg in patients with diastolic hypertension • A systolic pressure <140 mmHg except, perhaps, in patients with isolated systolic hypertension • Somewhat lower goals have been recommended in hypertensive patients with diabetes mellitus, chronic kidney disease, and coronary artery disease. • Blood pressure reduction should always be gradual in elderly patients.

36. Treatment of dyslipidemia • Clinical trials demonstrate clinical benefits as early as six months after starting the treatment. • In the CARE trial and the Heart Protection Study, the cardiovascular benefits of serum LDL reduction were similar in elderly and younger patients with diabetes • It is recommend beginning cholesterol-lowering therapy in elderly diabetics with a persistent LDL cholesterol value above 100 mg/dL , with a goal of 70 to 80 mg/dL . • This approach is particularly warranted in diabetic patients who already have cardiovascular disease. • It is also recommended to start drug therapy in those with a serum HDL cholesterol concentration below 35 mg/dL (0.9 mmol/L) or marked hypertriglyceridemia

37. As with the goal for glycemic control, goals for risk factor management (hypertension, hyperlipidemia) should be adjusted based upon elderly patients' life expectancy, co-morbidities, cognitive status, and personal preferences.

38. Aspirin •  The value of daily aspirin therapy in patients with known macrovascular disease is widely accepted. • A meta-analysis of a large number of secondary prevention trials found that the absolute benefit of aspirin was greatest in those over age 65 years with diabetes or diastolic hypertension • We currently recommend 75 to 162 mg of enteric-coated aspirin daily for all diabetic patients over age 40 years who do not have a contraindication to aspirin therapy.

39. Exercise •  Exercise is beneficial to help maintain physical function, reduce cardiac risk, and improve insulin sensitivity in patients with diabetes. • In older adults, exercise also improves body composition and arthritic pain, reduces falls and depression, increases strength and balance, enhances the quality of life, and improves survival • Patients with deconditioning at risk for falls should be referred to an exercise physiologist and/or physical therapist for muscle strengthening and balance training in a safe environment.

40. Case 1 82- year- old woman . Suffers from diabetes for last 22 years. Her weight 79 kg; height 159 cm ; BMI= 31.2.She complaints of fatigue , weakness; palpitations on minimal physical effort. Pains in her feet. She is constantly treated with : • Glucophage 850 mg x 3/ day • Gluben 5 mg x 3/day • Tritace 5 mg x 1/ day • Normiten 50 mg/ day • Norvasc 5 mg/ day • Aspirin 100 mg/day • Lipitor 20 mg/ day • In spite of the above treatment her HBA1C levels are 7.8-8.6% for last 10 months. Her lipids are at the target range and her creatinine 1.4 mg/dl. Her electrolytes are normal. CBC is normal . HB = 13.5 g/dl . Microalbumin = 78 mg/day ( urine) • Fundus: no evidence of retinopathy

41. Case 1 ( cont’d) • Her cognitive status is satisfactory. She functions well. • Physical activity: walks 40 min per day. • From her past : IHD; s/p multiple coronarographias . Mild CHF. • Hypertension; Hyperlipidemia; Obesity. • D. Nephropathy; Mild polyneuropathy. • Three months ago her family doctor added 4 mg of Avandia per day.

42. Now she is coming to visit you • Her lab. Tests show : Mild anemia HB= 11.6 G/dl • Creatinine =1.45 mg/dl • HBa1C = 7.9% • Liver enzymes elevation : 20% above upper normal limit . • She complaints of exacerbation of palpitations on effort. • Physical exam.: Obesity; Lungs are clear; Heart- mild tachycardia of 92 /min; BP 135/80. • Leg edema ++. Mild hepatomegaly . • She gained 5 kg and now her weight is 84 kg.

43. Treatment suggestions: • Stop Metformin • Stop Avandia • Change Gluben to NovoNorm • Start Lantus 20 units with titration of dose.