Diabetes in Older Adults: Prevalence, Complications, and Treatment Guidelines

1. Diabetes in Older Adults M.Nakhjavani., M.D. Division of Endocrinology, Diabetes, & Metabolism Tehran University of Medical Sciences

2. Diabetes in Older Adults More than one quarter of older adults (defined as aged 65 years and older) have diabetes, the highest prevalence of any age group. Older patients are disproportionately affected by diabetes complications, both acute hypoglycemia; and chronic cardiovascular disease events, end-stage renal disease, amputations.

3. Prevalence of IFG, undiagnosed diabetes, known diabetes, and total diabetes in adult population of Iran, 2011. http://dx.doi.org/10.1016/j.diabres.2013.12.034

4. Demographics of Iran According to the 2016 population census the population ofIran was 79.9 million, a fourfold increase since 1956.

5. Incidence (per 1000) of major diabetes complications according to age among adults with diabetes, 2009 (6). ER, emergency room; ESRD, end-stage renal disease; IHD, ischemic heart disease. [Reproduced from the National Diabetes Surveillance System at http://www.cdc.gov/diabetes]

6. Diabetes in Older Adults Despite the burden of diabetes in this age group, most of the clinical trials that have provided evidence for treating diabetes and preventing its complications have either excluded older patients entirely or excluded those who have multiple comorbidities and/or are frail

7. Diabetes in Older Adults Research in this area may entail simulations, modeling, or “real world” observational or database studies. It is not ever realistic to do randomized long-term outcome trials in the most vulnerable older patients for whom there is the least clarity on goals and strategies.

8. Key Points • Prediabetes is highly prevalent in older people • Interventions to delay progression from • prediabete to diabetes are effective in this • age group • The prevalence of type 2 diabetesincreases as • individualsage and exaggerates the incidence of • bothmicrovascular and macrovascularcomplications.

9. Key Points • Cliniciansshouldperformregular screening for • prediabetes and diabetes in the older population • and implement interventions as indicated in the • guideline

10. Key Points • The problemsthatolderindividualswithdiabetes • face, in contrast to younger people with the disease, include: • Sarcopenia, • Frailty • Cognitive dysfunction. • Such complications canlead to an increasedrisk of: • Poormedicationadherence • Hypoglycemia, • Falls and loss of independence in daily living activities.

11. Key Points • The guideline presentsevidence for the various • effects of diabetes in the older patients and the • relevant therapiesfoglycemic control, • hyperlipidemia and hypertension. • Guideline recommendationsalsoaddress • commomco-morbiditiessuch as renal • impairment,which affects th pharmacokinetics • and pharmacodynamics of specific • agents, and concomitant disease.

12. Treatment of Diabetes in Older Adults: An Endocrine Society Clinical Practice Guideline Treatment of Diabetes in Older Adults

13. Screening

14. Diabetes in Older Adults Cases; Screening She is a retired 75-year-old widowed female woman and busy looking after her grandkids. She has been in good health. She lives independently, cooks for herself and has no difficulty managing her ADL’s. She does have hypertension, which was diagnosed in her 50’s and has been well treated ever since. Her BP=125/78 and BMI=26.5 kg/m2. She has a strong family history of T2DM and HTN. On her annual screening FBS was 112 mg/dl.

15. Diabetes in Older Adults Cases; Screening Question: What is the next best test, according to the new Endo society CPG, to establish whether or not she has diabetes? HbA1c 2 hour post 75 gm OGTT Fructosamine 2 hour postprandial BG

16. Wu L, et al. PloS One. 2017;12(9)

17. Glucose Target-Assess Overall Health

18. Diabetes in Older Adults Cases: Glucose Target He is a 68-year-old man who has had T2DM since he was 50 years old. His control has been varied since diagnosis. He initially achieved an A1c of 7.2% but it increased to 9% over time. He was very reluctant to start insulin since he was a construction worker and he feared hypoglycemia while working. Additionally he was diagnosed with dyslipidemia and hypertension but had intermittent access to health case and was not consistent with taking his prescribed medications.

19. Diabetes in Older Adults Cases: Glucose Target He is now retired and has access to healthcare. His wife brings him to clinic concerned that he seems more forgetful and somewhat more disoriented that the past. Both of them wish to reassess his medical status and improve condition. He complains of chronic back and shoulder pain. He has intermittently blurry vision with a marked reduction in night vision. He notes nocturiax2. His weight is stable.

20. Diabetes in Older Adults Cases: Glucose Target On exam he appears older than stated age. He is oriented to person and place but not to date or time. His BP=165/95, BMI=27.4 kg/m2. He has bilateral cataracts and evidence of retinal bleeding on fundoscopic exam. His cardiac, pulmonary and abdominal exams are WNL. He has absent lower extremity reflexes and reduced pedal pulses. On foot exam his nails ate thickened, he has callus formation and a loss of propriocepion and sensation to 5.07 monofilament testing.

21. Diabetes in Older Adults Cases: Glucose Target-Assess Overall Health His HbA1c=9.2%. LDL=136 mg/dl, HDL=36 mg/dl and TG=237 mg/dl, eGFR=36 and 2+ protein in his urine. Question: what would be your initial target for HbA1c for this patient? Between 8-9 Less than 8.5 Between 7.5-8 Less than 7.5

24. Cognitive dysfunctionis the loss of intellectual functions such as: Thinking, Remembering Reasoning of sufficient severity to interfere with daily functioning. Patients with cognitive dysfunction have trouble with verbal recall, basic arithmetic, and concentration.

26. Mortality at 5 y by age and clinical groups

27. Medication Selection to Minimize Hypoglycemia

28. Diabetes in Older Adults Cases: Medication Selection to Minimize Hypoglycemia She is 77-year-old female with a 20+ year history of T2DM. In general she has been well controlled with an A1c of 6.8-7.5%. She eats carefully, takes her medications and walks 5 times per week. She was started on oral agents initially but for the past 10 years she has been on basal insulin and premeal rapid acting insulin. She uses a correction scale before meals. Recently she has noted a decrease in her appetite.

29. Diabetes in Older Adults Cases: Medication Selection to Minimize Hypoglycemia She fell and fractured her right wrist and this has made management of her diabetes more difficult. She lives with her daughter and son-in-law, but they work, so she is alone most of the day. She has had episodes of mild hypoglycemia several times per week lately. There is no particular pattern as to timing of these episodes. Her eGFR has fallen from 60 to 30 over the past two years. Her is BMI=24.5 kg/m2.

30. Diabetes in Older Adults Cases: Medication Selection to Minimize Hypoglycemia Question: Which approach would most safely and effectively reduce her risk of hypoglycemia? Attempting to taper off prandial insulin onto a regimen of basal insulin plus a DPPIV-Inhibitor B. Changing her rapid acting insulin to after-eating rather than before meals. Attempting to taper off prandial insulin onto a regimen of basal insulin plus metformin Adding a GLP-1 RA

32. Hospitalization Discharge Plan

33. Diabetes in Older Adults Cases This patient is a 78-year-old man with type 2 diabetes mellitus for 15 years, previously on metformin and sitagliptin. He also has hypertension and dyslipidemia. He is still active in the family business although his sons do most of the management now. He lives with his wife, who has early Alzheimer’s Disease. Recently, he developed chest pressure/dyspnea. He was admitted to a hospital and found to have an EF of 35% and multivessel coronary artery disease..

34. Diabetes in Older Adults Cases He underwent coronary-artery bypass graftingx3. In the hospital, he was treated with iv and then subcutaneous insulin. His postoperative course was complicated by abdominal pain and a bump in lipase/amylase. A CT scan was consistent with pancreatitis. This resolved without complications. When discharged, his insulin was discontinued and he was sent home on gliclazide 60 mg daily.

35. Diabetes in Older Adults Cases Discussion question: What do you think about the discharge regimen?

36. Diabetes in Older Adults Cases Discussion question: What do you think about the discharge regimen? After discharge, the patient had several blood sugar readings in the 60s on his meter. Ten days later, he became confused and his wife called their son. Blood glucose by meter was 42 mg/dl.

37. Diabetes in Older Adults Cases Discussion question: What do you think about the discharge regimen? He was admitted to a hospital for 3 days for hypoglycemia. He was sent home on no medications and referred to suggest a regimen. His blood sugars are running in the 200s and he is worried. He said, “My primary care doctor doesn’t want me on metformin unless my echo gets better.” He still has a poor appetite and has lost 9 kgs during the past few months.

38. Diabetes in Older Adults Cases Discussion question: What would you suggest for a diabetes regimen? He was started on glargine insulin by pen 15 U each morning. His kidney function was normal, and ideally he would have been restarted the metformin, but didn’t due to the primary care physician’s (PCP) concern about his congestive heart failure (which did not require medication).

39. Diabetes in Older Adults Cases Discussion question: What would you suggest for a diabetes regimen? The patient’s son faxed his blood sugars weekly, and titrated the glargine to 22 U daily with resulting blood glucose readings approximately 110–140 mg/dL. The next 6 months were complicated by episodes of major depression with some cognitive impairment. He was admitted once to the geriatric psychiatry unit. He eventually stabilized and has since done well. The couple now has a home health aide.

40. Diabetes in Older Adults Cases Discussion question: What would you suggest for a diabetes regimen? Six to twelve months later, the patient has no hypoglycemia and is in good spirits. He walks most days of the week and has no cardiac symptoms. His HbA1c is 7.2–7.5%. His cardiologist and PCP keep telling him (and me via notes), “it should be less than 7%. Discussion question: What do you think?

41. Case : Lipid Management

42. Diabetes in Older Adults Cases- Lipid Management He is a 80 years male with a 10 year history of type 2 diabetes. He has been treated with metformin and a DPP-IV inhibitor with and A1C of 6.6% . He has no family or personal history of CVD. He has no cardiac symptoms. He does not have hypertension. He is concerned because his LDL cholesterol level has been increasing and has gone up from 95 to 126 mg/dl.

43. Diabetes in Older Adults Cases- Lipid Management He has read that statin therapy should be started if his LDL cholesterol is above 100 mg/dl and wants your opinion as to whether or not they should start treatment. Question: You tell him: A. Gentle diet modification to lower his cholesterol B. Start on a statin C. Start on ezetimibe D. See a cardiologist for testing

45. Key Recommendation for Lipid Management •In patients aged 65 years and older with diabetes , we recommend statin therapy and the use of an annual lipid profile to achieve the recommended levels for reducing CVD events and all- cause mortality. Technical Remarks: •Since the Writing Committee did not rigorously evaluate the evidence for specific LDL-C targets in this population , we refrained from endorsing specific LDL-C targets in this guideline . •For patients aged 80 years old and older or with short life expectancy, we advocate that LDL-C goal levels should not be so strict.

46. Case Hypertension Management

47. Hypertension Management • SH is 76 years old white female with a 70 year history of type 1 diabetes . She is meticulous about her diabetes treatment . She prepares meals for herself and her husband , carbohydrate counts , using a continuous glucose monitor and is on an insulin pump . She walks daily for exercise.

48. Hypertension Management • She has had bilateral vitrectomies for retinopathy but her vision has been stable for many years . She had and MI when She was 62 , but fully recovered. She has mild peripheral neuropathy and an eGFR=46. She is treated for hypertension and dyslipidemia. She has osteoporosis which is treated with a bisphosphonate. She also has hypothyroidism for which she is on replacement. Her HbA1c is 6.5- 7.0%.

49. Hypertension Management Question : What is your blood pressure target for this patient? A.<140/90 B. <130/90 C.<130/80 D. <120/80

50. Key Recommendations for Hypertension Management In patients aged 65 to 85 years with diabetes , we recommend a target BP of 140/90 mmHg to decrease the risk of CVD outcomes, stroke , and progressive CKD Technical Remarks: •Patients in certain high –risk groups considered for lower BP targets (130/80mmHg) , such as those with previous stroke or progressing CKD (eGFR<60ml/min / 1.73 m2 and / or albuminuria )>>>>