Diabetes and the Older Patient

Report
DIABETES IN THE
OLDER PATIENT
AGS
Debra Bynum, MD
Associate Professor of Medicine
Division of Geriatric Medicine
University of North Carolina
THE AMERICAN GERIATRICS SOCIETY
Geriatrics Health Professionals.
Leading change. Improving care for older adults.
TRUE OR FALSE?
1. A healthy 90-year-old woman is likely to live to be 95.
2. Benzodiazepines are the most common cause of
emergency hospitalizations for adverse drug events
in older adults.
3. Patients over the age of 80 should not be treated for
systolic hypertension, because of an increased risk of
falls.
4. Compared with younger adults, older adults at risk of
DM have greater benefit from lifestyle modification in
preventing the development of DM.
Slide 2
OUTLINE
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Prevalence
Heterogeneity (Patients and Disease)
Specific Complications
Diabetes and Geriatric Syndromes
Diabetes in the Frail
Treatment Basics
Take-Home Points
Slide 3
FOCUS
How is diabetes different in the older patient?
Slide 4
TAKE-HOME POINTS
• Older adults with DM are heterogeneous in many ways
• Treatment of DM relies on treatment of the individual
• Do not avoid treatment in older patients based on age
 Older patients have higher risk of bad outcomes
 Modest treatment benefit is significant in high-risk populations
• But balance risks of treatment and goals of care in
patients with frailty or limited life expectancy
• Evidence suggests modest treatment goals (vs. tight
control) are associated with best outcomes
Slide 5
PREVALENCE
• Majority of patients with DM are over age 60
• 20%–30% of patients over age 65 have DM
• Many over age 60 may have undiagnosed DM
• CDC estimate: DM (diagnosed and
undiagnosed) affects 23% of people over 60
• Framingham data: 40% of those over 65 have
DM or impaired fasting glucose
Slide 6
INCREASING PREVALENCE
• Increasing overall prevalence of type 2 DM
with increasing age of US population and
increasing obesity
• Prevalence in long-term-care facilities:
increased from 16% in 1995 to over 20% in
2004
Slide 7
HETEROGENEITY: PATIENTS
• Average life expectancy 72–79 years
 At age 65, average life expectancy is to 82
 At age 85, average life expectancy is to 90
 Fastest growing population: over 85
• Differences:
 Age (65, 75, 85, 95, 100)
 Frailty and age are not equal
 Associated comorbidities
Slide 8
HETEROGENEITY: DISEASE
• Patients with long-standing type 2 diabetes associated
with family history, obesity, and metabolic syndrome
• Latent autoimmune diabetes in adults (LADA)
• Patients with long-standing type 2 DM with no family
history and normal BMI
• Patients with new diagnosis of DM after age 60
• Growing population of patients over age 60 with longstanding type 1 diabetes
Slide 9
COMPLICATIONS
• Hyperglycemia
• Hypoglycemia
• Nephropathy
• Visual loss
• Infection/amputation
• Cardiovascular disease
• Increased risk of geriatric syndromes
Slide 10
HYPERGLYCEMIA
• Dehydration
 Increased risk in elderly
 Decreased oral intake, decreased thirst mechanism
• Visual disturbance
• Confusion
• Increased urinary incontinence
• Increased risk of falls
Slide 11
NON-KETOTIC HYPERGLYCEMIC
HYPEROSMOLAR COMA
• Extremely high glucose in setting of extreme
dehydration
• Often associated with infection, myocardial event,
stroke
• More common than DKA in older adults, and higher
mortality
• Older patients with dementia, decreased access to
free water (nursing care setting), and decreased thirst
are at higher risk
Slide 12
HYPOGLYCEMIA (1 of 3)
Risk factors:
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Older age
Renal insufficiency
Long-acting oral agents (sulfonylureas)
Poor nutrition
Alcohol use
CHF
Post-hospitalization / frequent hospitalizations
Polypharmacy
Slide 13
HYPOGLYCEMIA (2 of 3)
• Risk 2%–9% in cohort studies
• Those over 75: double the rate of ED visits for
hypoglycemia compared with younger patients
• Associated with later development of dementia?
 Cohort study of patients followed for over 20 years1
 Patients with at least one episode of severe hypoglycemia
had increased risk of development of diabetes
 May be confounder and not causal
 See also CDC: Diabetes public health resource, 2012
(www.cdc.gov/diabetes)
1. Whitmer RA, et al. JAMA. 2009;301:1565-1575.
Slide 14
HYPOGLYCEMIA (3 of 3)
Risks of hypoglycemia:
• Falls and fracture
• Confusion and dizziness (more common
than sweating and shaking in older patients)
• Hospitalizations
• Increased risk of CV events?
Slide 15
EMERGENCY HOSPITALIZATIONS FOR
ADVERSE DRUG EVENTS
• Nearly 100,000 emergency hospitalizations for ADEs
in people over age 65 in the US each year
• Almost half of hospitalizations in those over age 80
• Majority are NOT due to notorious “high-risk”
medications, but due to commonly used medications
with proven benefit in older patients!



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Warfarin ― 33.3 %
Insulins ― 13.9%
Oral antiplatelets ― 13.3 %
Oral hypoglycemics ― 10.7%
Budnitz DS, et al. N Engl J Med. 2011;365:2002-2012.
Slide 16
NEPHROPATHY
• Overall, increases prevalence of renal
insufficiency and ESRD in older patients
• Older patients may have multiple etiologies for
renal failure (DM, HTN, medications)
• Microalbuminuria common (over 30%) and not
as predictive of future ESRD in older patients
 Highly predictive of CV and stroke risk
• ACE inhibitors still recommended
Slide 17
RENAL INSUFFICIENCY
“Normal creatinine” may not be normal
• Calculate GFR
• GFR depends on age, weight, sex
• Creatinine of 1.1 in a 98-pound woman is not
“normal”
Slide 18
VISION LOSS
• Often multifactorial
• Retinopathy often less progressive than in
younger patients with DM
• Glaucoma 3 times more common in older
patients with DM (11% vs. 4%)
• Cataracts more common and more rapidly
progressive
Slide 19
FOOT CARE
• 1/3 of older patients cannot see/reach feet
• Neuropathy is common and not always due to DM in
older patients (50% of patients over 80 have
peripheral neuropathy)
• Elderly with DM are at high risk of infection, cellulitis,
ulcers, gangrene, and amputation
• 10-year cohort study of patients with average age 751
 19% of DM group had episode of gangrene
 3% of DM group underwent amputation
1. Bethel MA, et al. Arch Intern Med. 2007;167:921-927.
Slide 20
CARDIOVASCULAR RISK
Challenges:
• Most older patients with DM will die of CVD
• Treatment-risk paradox:
 Older patients are at high risk of CVD
 Even small potential decrease in risk of CVD
could have big benefit and be worth the risk of
treatment
Slide 21
CVD: MODIFICATION OF
RISK FACTORS (1 of 2)
• There is evidence that older patients with DM,
CVD, hyperlipidemia benefit from treatment
with statins (similar to/better than younger
population)
• Recent studies show no additional benefit of
tight control
Slide 22
CVD: MODIFICATION OF
RISK FACTORS (2 of 2)
• There is evidence from multiple large studies
(SHEP, Syst-Eur) that older patients with
systolic hypertension benefit from treatment
 Decrease stroke
 Decrease CHF
• HYVET (Hypertension in the Very Elderly)
 Patients over age 80 benefit with decreased risk of
stroke, CHF, and mortality
Slide 23
HYPERTENSION IN OLDER PATIENTS
• Keys from studies:
 Treated systolic hypertension
 Targeted SBP 150
 Followed standing blood pressures
 Benefit seen even though significant number of
patients did not reach target SBP of 150
• Take-home point: Moderate SBP reduction in
the very elderly can have significant benefit!
Slide 24
COMPLICATIONS:
GERIATRIC SYNDROMES
Older patients with DM are more likely to have:
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Falls
Sarcopenia/muscle wasting
Malnutrition
Depression
Dementia
Urinary incontinence
Slide 25
DIABETES IN THE FRAIL
• More modest goals in BP and glucose control
• Balance quality of life
• Observe for other risks:
 Ulcers (heel and sacral)
 Malnutrition
 Dehydration
Slide 26
TREATMENT (1 of 5)
• Balance comorbidities, frailty, and life expectancy
• Target systolic hypertension and hyperlipidemia
 No evidence supports tight control
 Modest treatment reduces CV risk in older patients ―
do not avoid treatment based on age!!
 Relative risk reduction for secondary prevention of CV
events in older patients with DM is same as for younger
patients
• Given higher likelihood of CV events, this translates to
potential for greater absolute reduction of CV events
Slide 27
TREATMENT (2 of 5)
No evidence supports tight control of DM
• Target HbA1c of 7%–8% is suggested for most
older patients
• HbA1c of 8%–8.9% is associated with better
functional outcomes in community-dwelling,
NH-eligible older patients than in those with HbA1c
of 7%–8%1
• ACCORD, ADVANCE, and VADT trials: No benefit
of tight control, and older patients had higher risk of
hypoglycemic complications
1. Yau CK, et al. J Am Geriatr Soc. 2012;60:1215-1221.
Slide 28
TREATMENT (3 of 5)
Must take into account functional status and
availability/reliability of caregiver (LTC setting)
• Considerations for insulin and glucose monitoring:
 Vision
 Arthritis of hands
 Cognitive status
• Do not avoid treatment in functional, independent
patients or in those with needed support
Slide 29
TREATMENT (4 of 5)
• Treatment options are similar to those for younger
patients
• Metformin is an excellent option for many (with good
renal function) due to profile and lack of associated
hypoglycemia
• Avoid long-acting sulfonylureas such as glyburide ―
opt for shorter-acting agents such as glipizide
• Use pioglitazone with caution ― risk of fluid retention
and heart failure is greater in elderly
• Don’t avoid insulin (glargine, etc.)
Slide 30
TREATMENT (5 of 5)
• Smoking cessation
• Aspirin
 Greatest benefit is in patients over age 65 with DM
and/or diastolic hypertension, for secondary
prevention of known macrovascular disease
 Evidence for primary prevention of CV events in
patients with DM is still unclear
Slide 31
DIET AND LIFESTYLE (1 of 2)
• Medical nutrition therapy (MNT)
 RCT in patients over age 65: MNT decreased
fasting glucose by almost 20 points and improved
HbA1c by 0.5%
• Diabetes Prevention Program Study ― Those
over 60 compared to younger adults:
 Better adherence and meeting attendance
 Better response to diet/lifestyle modification
 Less, but still some, response to metformin in
preventing the development of DM
Slide 32
DIET AND LIFESTYLE (2 of 2)
• No evidence supports dietary restrictions in
frail elders
• Balance other concerns:
 Quality of life
 Malnutrition
 Vitamin deficiencies (vitamin D)
 Risk of fracture
 Depression
 Chewing/dental problems
Slide 33
TAKE-HOME POINTS
• Older adults with DM are heterogeneous in many ways
• Treatment of DM relies on treatment of the individual
• Do not avoid treatment in older patients based on age
 Older patients have higher risk of bad outcomes
 Modest treatment benefit is significant in high-risk populations
• But balance risks of treatment and goals of care in
patients with frailty or limited life expectancy
• Evidence suggests modest treatment goals (vs. tight
control) are associated with best outcomes
Slide 34
TRUE OR FALSE?
1. A healthy 90-year-old woman is likely to live to be 95.
True
2. Benzodiazepines are the most common cause of
emergency hospitalizations for adverse drug events
in older adults. False
3. Patients over the age of 80 with systolic hypertension
should not be treated, because of an increased risk
of falls. False
4. Compared with younger adults, older adults at risk for
DM have greater benefit from lifestyle modification in
preventing the development of DM. True
Slide 35
REFERENCES (1 of 2)
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Araki A, Ito H. Diabetes mellitus and geriatric syndromes. Geriatr Gerontol Int. 2009;9:105-114.
Barnett KN et al. Mortality in people diagnosed with type 2 diabetes at an older age: a systematic
review. Age and Ageing. 2006;35:463-468.
Beckett NS et al. Treatment of hypertension in patients 80 years of age or older. N Engl J Med.
2008;358:2887-2898.
Bethel MA, Sloan FA, Belsky D, Feinglos MN. Longitudinal incidence and prevalence of adverse
outcomes of diabetes mellitus in elderly patients. Arch Intern Med. 2007;167:921-927.
Budnitz DS et al. Emergency hospitalizations for adverse drug events in older Americans. N Engl J
Med. 2011;365:2002-2012.
Cahill M et al. Prevalence of diabetic retinopathy in patients with diabetes mellitus diagnosed after
the age of 70 years. Br J Ophthalmol. 1997;81:218-222.
Centers for Disease Control and Prevention. National Diabetes Fact Sheet: General Information and
National Estimates on Diabetes in the United States. 2011.
Cernea S, Buzzetti R, Pozzili P. B cell protection and therapy for latent autoimmune diabetes in
adults. Diabetes Care. 2009;32:S246-S252.
Cigolle CT, Blaum CS, Halter JB. Diabetes and cardiovascular disease prevention in older adults.
Clin Geriatr Med. 2009;25:607-641.
Diabetes Prevention Program Research Group. 10 year follow up of diabetes incidence and weight
loss in the Diabetes Prevention Program Outcomes Study. Lancet. 2009;374:1677-1686.
Duckworth W, Abraira C, Moritz T et al for the VADT Investigators. Glucose control and vascular
complications in veterans with type 2 diabetes. N Engl J Med. 2009;360:129-139.
Feil DG, Rajan M, Soroka O, Tseng C, Miller DR, Pogach LM. Risk of hypoglycemia in older
veterans with dementia and cognitive impairment: implications for practice and policy. J Am Geriatr
Soc. 2011;59:2263-2272.
Haas L. Management of diabetes mellitus medications in the nursing home. Drugs Aging.
2005;22:209-218.
Slide 36
REFERENCES (2 of 2)
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Joseph AJ, Friedman EA. Diabetic nephropathy in the elderly. Clin Geriatr Med. 2009;25:373-389.
Kirkman MS et al. Diabetes in older adults: a consensus report. J Am Geriatr Soc. 2012;60:2342-2356.
Knowler WC, Barrett-Connor E, Fowler SE et al for the Diabetes Prevention Program Research Group.
Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. N Engl J Med. 2002;
346:393-403.
Kyrou I, Tsigos C. Obesity in the elderly diabetic patient. Diabetes Care. 2009;32:S403-S409.
Miller ME, Bonds DE, Gerstein HC et al for the ACCORD Investigators. The effects of baseline
characteristics, glycaemia treatment approach, and glycated haemoglobin concentration on the risk of
severe hypoglycaemia: post hoc epidemiological analysis of the ACCORD study. BMJ. 2010;340:b5444.
Patel A, MacMahon S, Chalmers J et al for the ADVANCE Collaborative Group. Intensive blood glucose
control and vascular outcomes in patients with type 2 diabetes. N Engl J Med. 2008;358:2560-2572.
Schwartz AV et al. Diabetes related complications, glycemic control, and falls in older adults. Diabetes
Care. 2008;31:391-396.
Sinclair AJ, Paolisso G, Castro M et al for the European Diabetes Working Party for Older People.
European Diabetes Working Party for Older People 2011 clinical guidelines for type 2 diabetes mellitus:
executive summary. Diabetes Metab. 2011;37(suppl 3):S27-S38.
Whitmer RA, Karter AJ, Yaffe K. Hypoglycemic episodes and risk of dementia in older patients with type 2
diabetes mellitus. JAMA. 2009;301:1565-1575.
Yau CK et al. Glycosylated Hgb and functional decline in community dwelling, nursing home eligible
elderly adults with diabetes mellitus. J Am Geriatr Soc. 2012;60:1215-1221.
Slide 37
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