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Joslin Diabetes CenterAdvances in Diabetes and Thyroid Disease 2013Diabetes Mellitus in Older Adults
Copyright © 2013 by Joslin Diabetes Center, Inc. All rights reserved. These materials may be used for personal use only. Any distribution or reuse of this presentation or any part of it in any form for other than personal use without the express writtenpermission of Joslin Diabetes Center is prohibited.
Diabetes Mellitusin Older Adults
Medha Munshi, M.D.Joslin Diabetes Center
Beth Israel Deaconess Medical CenterHarvard Medical School
Presenter Disclosure Information
Medha Munshi
Research grant from Sanofi
Goals and Objectives
• Older patients vs younger adults
• Goals of treatment
• Management strategy
1
Joslin Diabetes CenterAdvances in Diabetes and Thyroid Disease 2013Diabetes Mellitus in Older Adults
Copyright © 2013 by Joslin Diabetes Center, Inc. All rights reserved. These materials may be used for personal use only. Any distribution or reuse of this presentation or any part of it in any form for other than personal use without the express writtenpermission of Joslin Diabetes Center is prohibited.
Diagnosed and Undiagnosed Diabetes
0
5
10
15
20
25
30
20-44 45-64 65 and over
2010
2005-2008 NHANES: national diabetes fact sheet 2011; CDC
Per
cen
tag
e
Case History
• 85 years old patient with diabetes
Questions:
- what is different in presentation?
- when does this patient need treatment?
- what is the best treatment for this patient?
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Joslin Diabetes CenterAdvances in Diabetes and Thyroid Disease 2013Diabetes Mellitus in Older Adults
Copyright © 2013 by Joslin Diabetes Center, Inc. All rights reserved. These materials may be used for personal use only. Any distribution or reuse of this presentation or any part of it in any form for other than personal use without the express writtenpermission of Joslin Diabetes Center is prohibited.
Heterogeneity in EnvironmentIn Older Adult With Diabetes
Communityliving
Alone
spouse
OtherFamily member
Older adultWith diabetes
FunctionallydisabledHighly
functional
Assisted carefacilities
Nursing home
Diabetes
Co-morbidities in Aging and Diabetes
Macro/Micro vascular dzCognitive dysfunction
DepressionPhysical disability
Polypharmacy
Aging
Cognitive DysfunctionExecutive Dysfunction
• Frontal lobe mediated higher functions– Insight in to the
problem
– Planning and judgment
– Problem solving
– Starting, changing or stopping behavior
3
Joslin Diabetes CenterAdvances in Diabetes and Thyroid Disease 2013Diabetes Mellitus in Older Adults
Copyright © 2013 by Joslin Diabetes Center, Inc. All rights reserved. These materials may be used for personal use only. Any distribution or reuse of this presentation or any part of it in any form for other than personal use without the express writtenpermission of Joslin Diabetes Center is prohibited.
Case History – Mr. D
• 82 yo male
• Engineer—computer savvy
• DM duration 17 yrs
• Glargine BID and lispro before meals
• A1C 6.5%
Please read and do the following carefully:
In the blue box on the next page:
Draw a picture of a clock
Put in all the numbers
Set the time to ten after eleven.
Hand this sheet back and go to the next page
InstructionForm:
ResponseForm:
Modified Clock-In-a-Box(CIB)
Cognitive Dysfunction in Older Adults With and Without DM
34
18.5
0
5
10
15
20
25
30
35
40
Older Adults without DM Older Adults with DM
>70 yrs
Munshi et al. Diabetes Care. 2006;29(8):1794-1799.Health and retirement study (CDC).
4
Joslin Diabetes CenterAdvances in Diabetes and Thyroid Disease 2013Diabetes Mellitus in Older Adults
Copyright © 2013 by Joslin Diabetes Center, Inc. All rights reserved. These materials may be used for personal use only. Any distribution or reuse of this presentation or any part of it in any form for other than personal use without the express writtenpermission of Joslin Diabetes Center is prohibited.
Cognitive Dysfunction Associated with Poor Diabetes Control
6.87
7.27.47.67.8
88.28.48.68.8
Cognitive Dysfunction Cognitively Intact
A1
C
P<0.002
Munshi et al. Diabetes Care. 2006;29(8):1794-1799
Depression in Older Adults With and Without DM
11
32
18
35
0
5
10
15
20
25
30
35
40
Older Adults without DM Older Adults with DM
Men
Women
Munshi et al. Diabetes Care. 2006;29(8):1794-1799.Health and retirement study (CDC).
Depressive Symptoms Associated with Increased Risk of Functional Disability
3
3.5
4
4.5
5
5.5
6
Without Depression With Depression
P<0.03
*
Munshi et al. Diabetes Care. 2006;29(8):1794-1799.
5
Joslin Diabetes CenterAdvances in Diabetes and Thyroid Disease 2013Diabetes Mellitus in Older Adults
Copyright © 2013 by Joslin Diabetes Center, Inc. All rights reserved. These materials may be used for personal use only. Any distribution or reuse of this presentation or any part of it in any form for other than personal use without the express writtenpermission of Joslin Diabetes Center is prohibited.
For Women Living Alone, Glycemic Control Worsens as Number of Medications Increases
5.00
5.50
6.00
6.50
7.00
7.50
8.00
8.50
9.00
9.50
0 5 10 15 20
Medication Count
A1
C
Hayes M et al; Diabetes 2006; A212
Functional Impairmentin the Elderly With Diabetes
Hearing Impairment 48 %
Vision Impairment 53 %
History of Recent Falls 33 %
Fear of Falls 43 %
Independent in ADL 95 %
Independent in IADL 38 %
Munshi et al. Diabetes Care. 2006;29(8):1794-1799.
CVD PVD
Retinopathy Nephropathy
Morbidityand Functional
Disability
Morbidity Mortality
Depression
PhysicalDisability
Cognitive Dysfunction
Polypharmacy
FallsNeuropathyUrinary
Incontinence
DiabetesMellitus
Hypoglycemia
Compliance
Quality of life
Complex Interactions in Older Adults with Diabetes
CAD
6
Joslin Diabetes CenterAdvances in Diabetes and Thyroid Disease 2013Diabetes Mellitus in Older Adults
Copyright © 2013 by Joslin Diabetes Center, Inc. All rights reserved. These materials may be used for personal use only. Any distribution or reuse of this presentation or any part of it in any form for other than personal use without the express writtenpermission of Joslin Diabetes Center is prohibited.
Management of Diabetes in Older Adults
• Screening for barriers– Clinical / Functional / Psychosocial
• Management of hyperglycemia– Medications– Diet– Exercise/Physical activity
• Management of risk factors– BP control <130/80 mm Hg– LDL cholesterol <100 mg/dl– Cessation of cigarette smoking– Low dose aspirin therapy– Yearly screening for microalbuminuria (ACE
inhibitors), retinopathy, foot examination
Goal- Setting
Glycemic Goal
HypoglycemiaSocial support and
Living situation
Life expectancyFinancial issues
Physical abilities
A1C: Marker of Glycemic Control
• Increases with increasing age
• Affected by red cell life span
• Role of renal dysfunction and anemia of chronic diseases not known
• Reflects average glucose – miss BG fluctuations
7
Joslin Diabetes CenterAdvances in Diabetes and Thyroid Disease 2013Diabetes Mellitus in Older Adults
Copyright © 2013 by Joslin Diabetes Center, Inc. All rights reserved. These materials may be used for personal use only. Any distribution or reuse of this presentation or any part of it in any form for other than personal use without the express writtenpermission of Joslin Diabetes Center is prohibited.
A1C - 8.2%
Insulin only
A1C - 8.3%
Insulin and oral
Hypoglycemia in older adults
Hypoglycemia &Fear of hypoglycemia
Noncompliance
Hypoglycemiaunawareness
Cognitive dysfunctioninterfering with
identification/treatmentof hypoglycemia
Co-morbiditiesmimicking
hypoglycemicsymptoms
Insulin therapy in older adults
Falls, hospital visitsExacerbation of
chronic conditions
Even mild hypoglycemia may result in poor outcome
Frequent Hypoglycemic Episodes Detected by CGM
age>70 yrs; A1C>8%; n=40
Patients with hypoglycemia n = 26 (65 %)
Patients with A1C 8-9 % 14 (54 %) Patients with A1C > 9 % 12 (46 %)
Severity of hypoglycemic episodes
60-69 mg/dl 100 %50-59 mg/dl 73 %< 50 mg/dl 46 %
Munshi et al; Arch Intern Med. 2011;171(4):362-364
8
Joslin Diabetes CenterAdvances in Diabetes and Thyroid Disease 2013Diabetes Mellitus in Older Adults
Copyright © 2013 by Joslin Diabetes Center, Inc. All rights reserved. These materials may be used for personal use only. Any distribution or reuse of this presentation or any part of it in any form for other than personal use without the express writtenpermission of Joslin Diabetes Center is prohibited.
Diabetes Care. 2012 Dec;35(12):2650-64 J Am Geriatr Soc. 2012 Dec;60(12):2342-56
Patient characteristics /health status
Rational A1C BP Lipids
Healthy- few co-existing illnesses- intact cognitive status- intact functional status
Longer life expectancy
<7.5% <140/80 Statins unlessnot tolerated
Complex/Intermediate- Multiple co-existing
illnesses- Mild-moderate cognitive
impairment- 2+ instrumental ADL
Intermediate life expectancyHigh treatment burdenHypo vulnerabilityFall risk
<8% <140/80 Statins unless not tolerated
Very Complex/Poor Health- LTC care residents- end-stage chronic illnesses- Moderate-severe cognitive
impairment- 2+ ADL dependencies
Limited life expectancyBenefits uncertain
<8.5% <150/90 Consider risks and beneftis
A Framework for Treatment Goals
Kirkman MS et al; Diabetes Care. 2012 Dec;35(12):2650-64
Current A1c
<7%
Multiple Comorbidities
or medications
that may cause
hypoglycemia
LiberalizeGoal
Few Comorbidities
andMedications unlikely to
cause hypoglycemia
At goal with caution(Continually assess for hypoglycemia)
7 – 8%
Medications likely to cause
hypoglycemia
Carefully assess for hypoglycemia
or glucose excursions
At Goal
Present Not Present
Medications unlikely to
cause hypoglycemia
> 8%
-Multiple Co-morbidities-Limited Life Expectancy-Difficulty coping
Aim for Goal < 8%
Present Not Present
Goal-setting Algorithmin Elderly
9
Joslin Diabetes CenterAdvances in Diabetes and Thyroid Disease 2013Diabetes Mellitus in Older Adults
Copyright © 2013 by Joslin Diabetes Center, Inc. All rights reserved. These materials may be used for personal use only. Any distribution or reuse of this presentation or any part of it in any form for other than personal use without the express writtenpermission of Joslin Diabetes Center is prohibited.
Class A1C Reduction
Fasting vs PPG
Hypo-glycemia
Weight Gain
Dosing (times/day)
Other Safety Issues
Metformin 1.5 Fasting No Neutral/Loss
2 GI, lactic acidosis
Insulin (long-acting)
1.5–2.5 Fasting Yes Gain 1, Injected
Insulin (rapid-acting)
1.5–2.5 PPG Yes Gain 1–4, Injected
Sulfonylureas 1.5 Fasting Yes Gain 1 Allergies,secondary failure
Thiazolidinediones
0.5–1.4 Fasting No Gain 1 Edema, CHF, bone fractures
GLP-1 agonist (short-acting)
0.5–1.0 PPG No Loss 2, Injected GI, ARF, ?pancreatitis
Repaglinide 1.0–1.5 Both Yes Gain 3
Nateglinide 0.5–0.8 PPG Rare Gain 3
Adapted from Nathan DM et al. Diabetes Care. 2007;30:753-759. | Nathan DM et al. Diabetes Care.2006;29:1963-1972. | Nathan DM et al. Diabetes Care. 2009;32:193-203. | ADA. Diabetes Care.2008;31:S12-S54. I WelChol PI. 1/2008. Cycloset PI. 5/2009. | Buse JB et al. Lancet. 2009;374:39-47.
ARF = acute renal failure; GI = gastrointestinal; GLP = glucagon-like peptide
15 Classes of Antidiabetes Medications
15 Classes of Antidiabetes MedicationsClass A1C
ReductionFasting vs PPG
Hypo-glycemia
Weight Gain
Dosing (times/day)
Other Safety Issues
α-Glucosidase inhibitor
0.5–0.8 PPG No Neutral 3 GI
Amylin mimetics 0.5–1.0 PPG No Loss 3, Injected GI
DPP-4 inhibitors 0.6–0.8 Both No Neutral 1 ?pancreatitis
Bile-acid sequestrant
0.5 Fasting No Neutral 1–2 GI
Bromocriptine 0.7 PPG No Neutral 1 GI
GLP-1 agonist (long-acting)
1.0–1.5 Both No Loss ≤1, Injected GI, ?pancreatitis, ?MTC, ?ARF
(SGLT-2 inhibitors)
<1 Both No Loss 1 ??
Adapted from Nathan DM et al. Diabetes Care. 2007;30:753-759. | Nathan DM et al. Diabetes Care.2006;29:1963-1972. | Nathan DM et al. Diabetes Care. 2009;32:193-203. | ADA. Diabetes Care.2008;31:S12-S54. I WelChol PI. 1/2008. Cycloset PI. 5/2009. | Buse JB et al. Lancet. 2009;374:39-47.
ARF = acute renal failure; DPP-4 = dipeptidylpeptidase-4; GI = gastrointestinal; GLP = glucagon-likepeptide; MTC = medullary thyroid cancer; SGLT-2 = sodium-glucose transporter-2
Insulin Action
10
Joslin Diabetes CenterAdvances in Diabetes and Thyroid Disease 2013Diabetes Mellitus in Older Adults
Copyright © 2013 by Joslin Diabetes Center, Inc. All rights reserved. These materials may be used for personal use only. Any distribution or reuse of this presentation or any part of it in any form for other than personal use without the express writtenpermission of Joslin Diabetes Center is prohibited.
Higher contribution of post-pradial glucose in hyperglycemia in
older vs younger adults
Munshi et al, J Am Geriatr Soc. 2013;61:535–541
TZDs
Diagnosis
SulfonylureaStart low and
Increase dose astolerated
GLP- 1 agonist
Add second and/or third agent as needed
Normal Abnormal
Renal function
MetforminStart @ 500 mg/d
Increase by 500 mgUp to 2000 mg/d
Cognitive function
No CHFNormal LFT
Algorithmfor themetabolic managementof older adults with diabetes
DPP 4 inhibitors
-Long acting and NPH or mix insulin in am
UncontrolledWith oral Meds
Long acting insulinPm dosing
OrNPH at bedtime
Post prandial hyperglycemia
High FBS
Long acting insulinAm dosing
Algorithmfor themetabolic managementof older adults with diabetes
-Low AM, high PM-memory loss
11
Joslin Diabetes CenterAdvances in Diabetes and Thyroid Disease 2013Diabetes Mellitus in Older Adults
Copyright © 2013 by Joslin Diabetes Center, Inc. All rights reserved. These materials may be used for personal use only. Any distribution or reuse of this presentation or any part of it in any form for other than personal use without the express writtenpermission of Joslin Diabetes Center is prohibited.
Use of serum c-peptide to simplify regimen in older adults
• Normal/high serum C-peptide: 65/100• Age: 79±14 yrs, DM duration: 21±13 yrs• Number of medications: 11 (range 4-18)
• Simplification completed in 35 patients• In 19 patients, patients completely off insulin• In 16 patients number of insulin injections were
decreased significantly
• Number of hypoglycemic episodes decreased• A1c improved from 8% to 7.4% (p<0.002)
Munshi et al; American Journal of Medicine 2009;122;395-97
Simplification of RegimenImproves Glucose Excursions
A1c 7.5% Aspart Mix 70/30 30 units BIDTime < 70mg/dL: 590 min Metformin 1000mg QAM, 500mg QPM
A1c 7.2% Glargine 40 units QAMTime < 70mg/dL: 0 min Metformin 1000mg BID
Munshi et al; abstract presentation at ADA June 2013
Summary
• Older patients vs younger adults– Clinical presentation is variable
• Goals of treatment– Consider co-existing conditions– Risks vs Benefit of treatment– A1c vs hypoglycemia - parameters for glycemic
goals
• Management strategy– Matching patients’ coping skills to the complexity
of the treatment– KISS
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