بسم الله الرحمن الرحيم

1. بسم الله الرحمن الرحيم

2. Endocrinology and aging BY: Dr.M.Valizadeh Associate professor of SBMUS

3. References list: • Diabetes in Older Adults: A Consensus Report (ADA & AGS 2012) • UpToDate 2013 • Standards of Medical Care in Diabetes (American Diabetes Association 2013) • Williams text book of endocrinology (tenth edition) • Guidelines for improving the care of the older person with DM (American Geriatrics Society 2003)

4. outlines: • Introduction • DM in old age • Prevalence and outcome • Goals of management • Glycemic control or others risk factors • Special consideration • Case studies

5. Introduction: • The two most important clinical change in endocrine activity: • Pancreas: 40% 65-74 yr IGT or DM • ↓insulin secretion, peripheral insulin resistance (poor diet, physical inactivity, ↑ abdominal fat mass, ↓lean body mass) • Thyroid: 5-10% ↓T4,↑TSH • ↓T4 degradation( low T3) • Others: • Menopause (andropause) • Adrenopause • Somatopause (GH-IGF-1)

6. Diabetes mellitus in old age

7. Prevalence: • proportion of adults aged 65 to 74 with physician-diagnosed DM at nearly 25% in some ethnic groups. • Estimates from the Centers for Disease Control and Prevention indicate that, in 1998, 12.7% of persons aged 70 and older had a diagnosis of DM, up from 11.6% in 1990. There are also large numbers of older adults, almost 11% of the U.S. population aged 60 to 74, with undiagnosed DM.

8. Prevalence: • > 25% old age population of US (patients over the age of 65 years) have diabetes Mellitus.

9. Pathogenesis: • Aging: • Impaired glucose induced insulin release • Resistance to insulin mediated glucose disposal • Drugs such as: • Thiazides • Corticosteroids • Life style factors: • Low intake of complex carbohydrate • Physical inactivity • obesity

11. Outcome: • Older person with DM have higher rate of: • Premature death • Functional disability • Coexisting illness (HTN, CHD, Stroke)

12. Older adults with diabetes are also at greater risk than other older adults for several common geriatric syndromes, such as polypharmacy, depression, cognitive impairment, urinary incontinence, injurious falls, and persistent pain.

13. Moderate glycemic control: • Enhancement of wound healing • Reduction of symptoms • Maximization of cognitive function • Quality of life

14. Aggressive management→ harm • Hypoglycemia with tight blood sugar control • Risk of severe or fatal hypoglycemia increase exponentially with age • Altered release of glucagon • Autonomic warning symptoms • Psychomotor performance in response to hypoglycemia • Hypotension with aggressive blood pressure control

15. When and how to prioritize intervention targeting BP, glycemia, Lipid, aspirin use?

16. General guiding principles for the care of older adults with DM: • Specific goals of care or target outcomes • Feasibility of medication dosing and costs. • Keep care simple and inexpensive

17. Glycemic control or other risk factors: • Greater reduction in mortality or morbidity may result from control of cardiovascular risk factors than from tight glycemic control. • 8yearsare needed before the benefits of glycemic control • 2-3 yrsare required to see benefits from better control of BP and Lipids.

18. Hypertension: • Less than 130/80or 140/90 • HTN should be treated gradually to avoid complications (no more than 20 mmHg) • Lower BP • WITHIN 3 MONTHS 140-160 • Within 1 month if > 160/100 (IIIB) • ACEI or ARB → renal function and K within 1-2 weeks (IIIA) • Thiazide or loop diuretics → electrolytes within 1-2 weeks

19. smoking • ↑morbidity and premature death • 2-3 yrs of smoking cessation

20. Lipids : • On initial assessment LDL< 100, HDL> 40, Triglyceride < 150mg/dl → every 2 years or less in moderate to high risk lipid level • LDL < 100 mg/dl rechecked at least every 2 years • 100-129: MNT and ↑ physical activity (rechecked at least annually) • 130mg or more → pharmacologic therapy + lifestyle modification • HDL > 40mg/dl • Triglyceride < 150 mg/dl

21. Aspirin: • Primary prevention: • Secondary prevention • 81-321 mg/d • 1-10/1000 in old age ↔ 3/10000 middle age

22. Condition of patients • older adults with diabetes have little comorbidity and are active.→Use of common guide lines.

23. Treat to Target • FBS < 140 mg/dl ( 90-130 ) • BS < 180 mg/dl • HbA1C < 7% (<20% upper limit of normal) • BP < 130/80 • LDL-C < 100 mg/dl • Triglycerides < 150mg/dl

24. Condition of patients • older adults with DM are frail and have other underlying chronic conditions, substantial DM-related comorbidity, or limited physical or cognitive functioning,→enhance quality of life ( treatment symptoms of hyperglycemia and related complications of DM) and common geriatrics syndromes

25. Treat to Target • FBS < 150 mg/dl ( 90-150 ) • BS < 200 mg/dl • HbA1C < 8% (<30% upper limit of normal) • BP < 140/80 • LDL-C < 100 mg/dl

26. DM education: • Following information about hypo and hyperglycemia: • Precipitating factor • Prevention • Symptoms and monitoring • Treatment • When to notify a member of the health care team (IA) • Self monitoring of blood glucose

27. Nonpharmacologic therapy: • Appropriate MNT and content of his or her diet

28. Exercise: • Benefits of exercise and available resources for becoming more active

29. Precautions and Considerations • Consult a physician • Rule out significant cardiovascular diseases or silent ischemia • Prevent hypoglycemia with self-monitoring of capillary blood glucose (SMCBG) both before and after exercising • Strenuous exercise not recommended for people with poor metabolic control and significant complications

30. Elderly patient • DJD • CAD • Depression • Risk of falling • Cold weather

31. Even patients with poor health status → modest increase

32. Pharmacologic treatment: • Older patients can be treated with the same drugregimens as younger patients, but special careis required in prescribing and monitoring drug therapy.

33. Drugs: • Metformin is often contraindicated because of renal insufficiency or heart failure. • Sulfonylureas and other insulin secretagogues can cause hypoglycemia. • Glibenclamide 5mg • Gliclazide 80 mg • Repaglinide (0.5-1- 2 mg)

34. Drugs: • Insulin: can also cause hypoglycemia as well as require good visual and motor skills and cognitive ability of the patient or a caregiver. • Thiazolidinediones: should not be used in patients with CHF (New York Heart association [NYHA] Class III and IV). • Alfa glucosidase inhibitors: Acarbose 50,100 mg

35. Dose titration • Drugs should be started at the lowest dose and titrated up gradually until targets are reached or side effects develop. • As well as regards blood pressure and lipid management, the potential benefits must always be weighed against potential risks.

36. Notification: • Frail older adults are at higher risk for serious hypoglycemia • metformine contraindication: Creatinin • >1.5mg/dl in male • > 1.4 mg/dl in female • > upper limit normal for age • age 80 or more or reduced muscle mass→ timed urine collection

37. Glycemic control and monitoring: • HbA1c: • 7% or lower (active patient with little comorbidity) • About 8% (frail and complicated patient) • Monitoring: • At least every 6 month • Every 12 month (if stable A1c)

38. Eye care: • High risk: (at least annually) • Symptoms of eye disease • Evidence of retinopathy, glucoma or cataract • A1c > 8% • Type 1 DM • BP> 140/80 • Low risk at least every 2 years

39. Foot care: • At least annually (IIIA) • More frequent in high risk person (II) • Most current recommendation: at all nonurgent visit

40. Nephropathy • Microalbumin test annually • Serum Creatinin

41. Geriatric syndrome: • Depression • Poorer outcomes of DM care for patients with unrecognized depression.

42. Geriatric syndrome: Polypharmacy: • Risk factor for falls • Potential cause of depression • Cognitive impairment (delirium or dementia) • Urinary incontinence • Failure to thrive

43. Geriatric syndrome: • Cognitive impairment • ↓memory, learning, verbal skills • Hyperglycemia may be a treatable cause of cognitive impairment • Urinary incontinence: • Polyuria • Overflow incontinence • UTI • Candida vaginitis • Fecal impaction

44. Geriatric syndrome: • Injurious falls • pain

45. مورد 1: • آقای 68 ساله ای با سابقه 3 ساله هیپرتانسیون با شکایت پرنوشی و پرادراری، و ناکتوری 4 بار طی شب از 3 ماه پیش مراجعه کرده، طی اینمدت 2 Kg کاهش وزن داشته • روزی یک عدد انالاپریل 5 مصرف می کند،/ سابقه مشکل قلبی یا علامتی دال برآن ندارد • روزی 15 دقیقه پیاده روی دارد، حال عمومی وی خوب است • BP: 130/80 BW: 70 Kg (BMI: 27 Kg/m2) • در آزمایشات بعمل آمده: • FBS: 260 BS: 320 Creatinin: 1.1 • UA: glucose 2+ ketone: -

46. Glycemic control

47. مورد 2: • خانم 66 ساله ای با سابق 3 ساله دیابت مراجعه کرده، اخیرا بعلت هیپوگلیسمی و کاهش سطح هوشیاری در بیمارستان بمدت یکهفته بستری بوده، به همراه همسر 75 ساله و ناتوان زندگی می کند و برنامه غذایی متغیری دارد (ساعات صرف غذا). در حال حاضر روزی 2 عدد گلی بن کلامید و 2 عدد متفورمین مصرف می کند. سابقه مشکل قلبی یا علامتی دال بر آن ندارد. 8 سال پیش کله سیستکتومی شده. نسبتا سرحال می باشد • BP: 150/80 (* 5-6) BW: 54 Kg (BMI: 23 Kg/M 2) • FBS: 110 Hb A1c: 6.2 Creatinin: 0.9 UA: NL

48. BP: • Glycemic control:

49. مورد 2 : • خانم 70 ساله ای با کمک دخترش به مطب آورده شده، بسختی راه می رود. سابقه 10 ساله هیپرتانسیون، 5 ساله دیابت دارد و جهت پی گیری مراجعه کرده، اتنولول روزی 200 میلی گرم، گلی بن کلامید روزی 2 عدد، آسپیرین 80 روزانه، کلسیم-د روزانه، کپسول اومگا-3، نورتریپتیلین 25 ، کپسول امپرازول، دیکلوفناک 25 2 بار در روز مصرف می کند/ سابقه سکته قلبی 3 سال پیش و 2 بار بستری در CCU را ذکر می کند. /

50. از بی اختیاری که از یکماه پیش تشدید شده شکایت دارد • همچنین گزگز شبانه پاها از 4 ماه پیش دارد • BP: 160/80 BW: 50 Kg • FBS: 210 BS: 250 Hb A1c: 9.5% Creatinin: 1.3 • 10 5