ENDOCRINE DISORDERS in the ELDERLY Module #1 DIABETES

1. ENDOCRINE DISORDERS in the ELDERLYModule #1DIABETES Ed Vandenberg, MD, CMD Geriatric Section OVAMC & Section of Geriatrics 981320 UNMC Omaha, NE 68198-1320 evandenb@unmc.edu Web: geriatrics.unmc.edu updated11-18-06

2. PROCESS A series of modules and questions Step #1: Power point module with voice overlay Step #2: Case-based question and answer Step # 3: Proceed to additional modules or take a break

3. OBJECTIVES:All three modules Upon completion the Learner will be able to: 1) Describe the diagnosis and management of diabetes in the elderly 2) List the modifications of DM therapy for the frail and chronically ill elderly 3) Describe the most common etiologies, the evaluation and treatment of adrenal and thyroid disease 4) List the diagnostic procedures and treatment of Pagets’ disease

4. OBJECTIVES:Module one Upon completion, the learner will be able to: 1) Describe the diagnosis and management of diabetes in the elderly 2) List the modifications of DM therapy for the frail and chronically ill elderly

5. DIABETES • Definition and Classification (ADA) Diabetes mellitus is a group of metabolic diseases characterized by hyperglycemia resulting from defects in insulin secretion, insulin action, or both. • Type 1:Caused by an absolute deficiency of insulin secretion. • Type 2:Caused by a combination of resistance to insulin action and an inadequate compensatory insulin secretory response.

6. Pathophysiology Why the high prevalence? • Genetics • Obesity • Inactivity • Age related -pancreatic B-Cell function -reduced glucose transporters

7. Criteria for Diagnosis One or more of the following: • Symptoms of diabetes (eg, polyuria, polydipsia, unexplained weight loss)plus casual ( nonfasting) plasma glucose concentration ≥200 mg/dL • Fasting plasma glucose ≥126 mg/dL ( fasting = no caloric intake for ≥8 h) • 2 h Plasma glucose ≥200 mg/dL during an Oral Glucose Tolerance Test (OGTT) * Note: Diagnosis should be confirmed by repeat FBS on a subsequent day. *OGTT : 75 gm of glucose in 300 ml of water given after an overnight fast

8. Pre-diabetes Either of the following: • Impaired fasting glucose:Defined as fasting plasma glucose ≥110 and <126 mg/dL • Impaired glucose tolerance: Abnormal random plasma glucose concentration or response to OGTT but not meeting diagnostic criteria for diabetes

9. Metabolic Syndrome Increased risk of; CAD, PAD, and DM II Definition (three or more of the following); 1)Waist circ.: men> 40”, women> 35” 2) Fasting triglycerides > 150 mg/dl 3) HDL: Men < 40, women < 50mg/dl 4) BP > 130/85 mm Hg 5) FBS > 110 mg/dl Management: weight loss, exercise, control of risk factors

10. EVALUATION Evaluate for Comorbid Conditions • Medication review diuretics, adrenergic agonists, glucocorticoids, caffeine, nicotine, alcohol, and phenytoin • Family history • Smoking • Hypertension • Hyperlipidemia

11. Goals of Treatment(per ADA, AGS) Outpatient • Average preprandial capillary blood glucose; 80–120 mg/dL • Average bedtime capillary blood glucose; 100–140 mg/dL • HbA1c: • <7% in non frail(ADA) • <8% in frail or life expectancy <5 yr or high risk of hypoglycemia, polypharmacy or drug interaction (AGS)

12. Goals of Treatment(per ADA, AGS) Inpatient: -ICU: ≤110 mg/dL -Noncritical-care units: -preprandial: ≤110 mg/dL -postprandial: ≤180 mg/dL

13. Nonpharmacologic Interventions: • Individualize nutritional therapy • High-fiber diet • Life style (eg, regular exercise, alcohol and smoking cessation) • Patient and family education for self-management • Self-monitoring of blood glucose

14. Management of Co-Morbidities and Complication prevention • HTN: BP goal <130/80 mm Hg • Treat Lipid disorders: Goals: (NHLBI), -LDL <70 mg/dL -HDL >40 mg/dL, -TG <150 mg/dL (If total cholesterol ≥135 mg/dL, statin therapy to reduce LDL by ~30% regardless of baseline LDL (ADA); -Statins should be used as primary prevention against macrovascular complications • ACE inhibitor or angiotensin II receptor blocker (ARB) (if albuminuria, HTN, or another cardiovascular risk factor) • Daily ASA EC 81 -325 mg per day

15. Pharmacologic Interventions for Type 2 Stepped therapy: Step 1. Monotherapy -sulfonylurea agent ( 2nd-generation) -metformin -α-glucosidase inhibitor -thiazolidinedione Step 2. Combination therapy with 2 or more agents with different actions Step 3. Add insulin hs or switch to insulin bid

16. Oral Agents for Treating Diabetes Mellitus(1), (2)

17. Oral Agents for Treating Diabetes Mellitus(1), (2)

18. Oral Agents for Treating Diabetes Mellitus(1), (2)

19. Oral Agents for Treating Diabetes Mellitus(1), (2)

20. Insulin therapy (1), (2)

21. Newer injectable agents (1), (2),

22. Monitoring Diabetes (ADA) Each visit: • Weight, BP and feet: (including monofilament, palpation, and inspection) HbA1c • twice/yr in patients with stable glycemic control • quarterly, if poor control Eye • Annual comprehensive dilated eye and visual examinations by an ophthalmologist or optometrist who is experienced in management of diabetic retinopathy Lipid profiles • every 1–2 yr depending on whether values are in normal range Microalbuminuria • Annual (unless microalbuminuria has previously been demonstrated) test by measuring albumin:creatinine ratio in a random spot collection

23. The End of Module One on Endocrine disorders in the ELDERLYDIABETES

24. Post-test According to recommendations of the American Diabetes Association, which of the following criteria establishes a diagnosis of diabetes mellitus? A. Fasting plasma glucose of 110 to 126 mg/dL B. Fasting plasma glucose ≥ 110 mg/dL on two occasions C. Fasting plasma glucose ≥ 126 mg/dL on two occasions D. Classic symptoms of diabetes mellitus plus random plasma glucose ≥ 126 mg/dL E. Plasma glucose ≥ 120 mg/dL after 2 hours during a standard oral glucose tolerance test, on two occasions Used with permission from: Murphy JB, et. al. Case Based Geriatrics Review: 500 Questions and Critiques from the Geriatric Review Syllabus. AGS 2002 New York, NY.

25. Answer; C. Fasting plasma glucose ≥ 126 mg/dL on two occasions The current classification of diabetes mellitus is based upon cause rather than age of onset or type of treatment. Four major types are recognized: type 1, type 2, gestational, and hyperglycemia secondary to other causes. Measurement of fasting plasma glucose is the recommended diagnostic test; oral glucose tolerance testing no longer is recommended for diagnostic use except in testing for gestational diabetes. The criterion for diagnosis of diabetes mellitus is fasting plasma glucose ≥ 126 mg/dL on two occasions.

26. Three unequivocal criteria for a diagnosis of diabetes mellitus have been defined: 1) Symptoms of hyperglycemia with a casual blood glucose of ≥ 200 mg/dL, 2) fasting blood glucose ≥ 126 mg/dL, and 3) a 2-hour blood glucose of ≥ 200 mg/dL after a 75-gram oral glucose tolerance test. These criteria should be confirmed by repeat testing on a different day. • A separate category of “impaired glucose tolerance” is indicated by 1) fasting blood glucose of ≥ 110 mg/dL but < 126 mg/dL, or 2) a 2-hour blood glucose of ≥ 140 mg/dL but < 200 mg/dL with a 75-gram oral glucose challenge. End

27. Readings and Resources Recommended readings and resources Blaum CS. Diabetes Mellitus. Geriatric Review Syllabus 6th edition 2006, pp382-389 Rueben DB, Herr KA, Pacala JT, Pollock BG, Potter JF, Semla TD. Endocrine Disorders, Geriatrics at Your Fingertips. 8th edition pps. 62-65 Resources; (1) Epocrates accessed 11-18-06 (2) Blaum CS. Diabetes Mellitus GRS 6th edition 2006, pp382-389