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Diabetes and The Older Patient

Diabetes and The Older Patient. Where we’ve been, where we’re going… Debra L. Bynum, MD Division of Geriatric Medicine. Objectives. 1. Review the treatment options in caring for older patients with diabetes 2. Understand the risks of hyperglycemia and hypoglycemia in older patients

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Diabetes and The Older Patient

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  1. Diabetes and The Older Patient Where we’ve been, where we’re going… Debra L. Bynum, MD Division of Geriatric Medicine

  2. Objectives • 1. Review the treatment options in caring for older patients with diabetes • 2. Understand the risks of hyperglycemia and hypoglycemia in older patients • 3. Appreciate the importance of cardiovascular risk reduction in older patients with diabetes by treating hypertension and hyperlipidemia • 4. Gain awareness of an association with diabetes, HTN, and vascular risk factors with dementia • 5. Understand the complexities associated with “brittle” diabetes in frail older patients

  3. Outline • Prevalence • Acute complications • Treatment options and goals • Tube feeding, type 1 diabetes, nursing home care • Risks of longstanding diabetes • Reducing cardiovascular events: treating hypertension and dyslipidemia • Dementia: association with cardiovascular risk factors; ?can we prevent it?

  4. Cases

  5. Case Study #1 • 78 y/o nursing home resident presents for evaluation of recurrent episodes of severe hypoglycemia. Diagnosed at age 65 on insurance exam. Treated with sulfonylurea without response for ~1 year. Subsequently treated with insulin. Currently treated with Novolog 70/30 14 units in the AM and Lantus 10 units at bedtime. Glucose logs reveal 4-6 readings per day ranging from 30’s to mid 500’s over the last 2 weeks. Severe hypo is usually during the afternoon or in the early AM. Average on meter 195 mg/dL with SD 130 mg/dL • PMH: None. FH: No early vascular disease. SH: No habits • PE: 61”, 98 lbs, 138/66, 82. Exam normal for age • A1c=8.6%; Creatinine=1.3, TC=150, HDL=70, LDL=70, TG=50

  6. Case 1: • Does this patient have type 1 diabetes? • How would you treat this patient?

  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. • Would metformin therapy be a consideration for this patient? What would be the risks?

  9. Case study #3 • An 88 year old woman with significant depression, HTN, chronic pain with spinal stenosis and a long history of an obsessive compulsive personality disorder is admitted to the hospital with confusion and dehydration. She takes insulin faithfully, and is found to have a glucose of 23 on admission. History reveals that she has been more depressed, and has lost 15 pounds which puts her now at 83 pounds…

  10. Case #3… • Further history reveals that she has not been sleeping, and is wearing plastic gloves for fear of germs. Her HgbA1C is 6.1%, and she is very afraid of losing optimal control so has restricted her diet so that now she is eating only one bowl of rice a day. She divides this into three portions so she does not overwhelm her system with “carbs…”

  11. Case # 3… • Describe her mental illness and how this is impacting upon care of her diabetes. • How should dietary restrictions be approached in the elderly, especially those who may be at baseline undernourished, underweight or at risk for missing meals?

  12. Case # 4 • 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.

  13. Case # 4… • How tight should control be for this patient? What would be an optimal HgbA1C? • What would be the potential benefits of treating her diabetes and hypertension more aggressively? What would be the risks? • Does the fact that she is in the nursing home setting make you more or less likely to treat her diabetes and hypertension aggressively?

  14. Case # 5 • 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 150/70, her PE is unremarkable.

  15. Case # 5 • 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 150/70, her PE is unremarkable.

  16. Case study 5 • 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?

  17. 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

  18. Some Numbers… • Aging of America • Prevalence of Diabetes • Over 10% those over 65 • Framingham Data: Diabetes or impaired glucose tolerance (fasting glucose 120-139) in nearly 40% those over 65 • Prevalence of Cardiovascular Disease • Prevalence of Dementia

  19. Some Numbers… • Aging of America • Prevalence of Diabetes • Prevalence of Cardiovascular Disease • Heart disease and stroke: 1st and 3rd leading causes of death • 60% deaths in those over 85 due to CVD • Morbidity: stroke and CHF • Cardiovascular Health Study: new events over 10 years • Coronary Disease: 39.6/1000 person yrs for men, 22.3 for women • Stroke: 14.7/1000 person years • CHF: over 6% per year in those over 85 • Prevalence of Dementia

  20. 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 to have 2 million centenarians in US! • Leading public health concern as the new chronic disease…

  21. 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… • Hyperglycemia upon admission in patients with no prior hx of DM associated with worse outcomes/higher mortality

  22. Diabetes: Diagnosis • Same standards to diagnose • Fasting glucose over 140 • Impaired glucose metabolism with fasting glucose 120-139 • ? increased risk even in this group • 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, less risk than in those with diagnosis of DM

  23. Hyperglycemia • Dehydration • Increased risk in elderly due to decreased intake and decreased thirst mechanism • Can lead to falls, confusion • Visual disturbances • Significant hyperglycemia distorts lens leading to increased blurring of vision • Confusion

  24. 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

  25. 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

  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 • Overall same • Sulfonylureas • Metformin • Lactic acidosis: increased with renal insufficiency • ?contraindication in over 80 • Contraindications: contrast dye, liver disease, ETOH, severe infection/acute illness • Alpha-glucosidase inhibitors (acarbose) • Thiazolidinediones (rosiglitazone, pioglitazone) • Pro: can be used with renal insufficiency • Cons: costly, edema and volume overload

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

  29. 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

  30. Treatment Goals • Individualized • No data for tight control… • Most recommend Hgb A1c 7-8% • Other options: • Tight control: healthy “young” with likely long 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

  31. Some special circumstances • Tube feeding • Increases hyperglycemia • Specialized formulas • Acute setting: continuous insulin • Long term: basal insulin with glargine; with bolus feeds, consider short acting insulin prior to bolus • Type 1 diabetes • More common in younger patients but can occur in older patients • DKA • “brittle” with episodes of hypoglycemia

  32. Nursing home setting • Decreased prevalence in older residents (?5%) • 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

  33. Nephropathy • No recommendation to screen for microalbuminuria in patients with normal renal function • Lower risk of ESRD in older patients with DM • Long interval between presence of albumin and ESRD, so previously not considered in over 70 group • ?whether this will change • 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

  34. 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 …

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

  36. 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 • Nursing home setting may provide better monitoring, medication compliance

  37. The Big Goal of Treatment: Prevention of Cardiovascular Events…

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

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

  40. 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)

  41. Treatment of Hypertension • Choice of agents: • Thiazide diuretics (HCTZ, maxzide) • Good news: ALLHAT study: JUST AS EFFECTIVE AS THE MORE EXPENSIVE, NEWER MEDICATIONS! • ACE inhibitors, angiotensin II receptor blockers, long acting calcium channel blockers • Beta blockers in those with indication ( MI); some concern that may not be as effect as thiazides, ace inhibitors in prevention of CV events

  42. Treatment of HTN • Orthostasis present in 30% people over age 75 • Care to prevent orthostatic hypotension in older patients with treatment • Some concern that too much lowering of DBP (leading to increased Pulse Pressure) is associated with higher rates of CV events • Treated patients still fared better than placebo • Higher PP likely MARKER of bad outcomes (possibly associated with “stiffer” arteries), not necessarily the CAUSE of bad outcomes…

  43. Systolic Hypertension and Dementia… • Epidemiological studies originally demonstrated associated 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!

  44. Dementia • Systolic Hypertension and Diabetes seem to be independent risk factors for dementia • Not only vascular dementia, also associated with alzheimer type dementia • SH, DM, and dementia all more common with aging: a difficult web to untangle… • But dementia seems to be related to or worsened by traditional cardiovascular risk factors…

  45. Treatment of SH: Summary • Treatment of SH in older patients decreases the risk of stroke, CHF, and combined CV events • Evidence that treatment of SH prevents dementia… • Aging and HTN as huge risk factors for CVD • Aging, HTN and DM HUGE risk for CVD • Treatment of CVD risk factors such as HTN critical treatment of older patients with DM • Thiazide diuretics cheap and effective in older patients • ACE inhibitors effective and studies show well tolerated with no impact on QOL

  46. Hyperlipidemia • Previously many older patients not treated • Thought that statin agents took years to have effect, and that those over age 70 would not see benefit • Often cited “lack of data” in older group • Worry about increased risks • But… • Newer evidence that statin agents work short term • Newer thoughts about average lifespans… • Lack of data due to prior studies excluding older patients, not due to lack of observed benefit in trials… • So far, increased risks of rhabdo and liver disease have not really panned out in older patients

  47. Hyperlipidemia • More studies now addressing treatment of hyperlipidemia in older patients • CARE trial: diabetic patients with LDL <130 benefited from statin agents to further reduce cholesterol, regardless of age • Heart Protection Study: those over 75-80 had a GREATER reduction in cardiovascular events (29%) compared to the younger patients in the trial (25%)

  48. Summary of studies…

  49. Hyperlipidemia • Given fact that older patients have much higher risk of CV events, then the same relative risk reduction by treating this group will have overall GREATER absolute risk reduction • If 5 % patients are at risk, and treatment reduces this by 50%, then 2.5% will have event, ARR of 2.5% • If only 2% are at risk, RRR of 50% decreases the incidence to 1%, ARR of 1% • If more patients are at risk, then more will benefit • The greatest benefit can be seen in those who are the greatest risk!

  50. Hyperlipidemia • Treatment groups: • Older patients with DM • Older patients with prior CV event (stroke, MI, CHF) • All older patients with hyperlipidemia? • Burdon of asymptomatic atherosclerosis HIGH • Patients over age 70 should be considered very likely to have underlying CAD/CVD (much as those with diabetes): the new Cardiovascular equivalent

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