Download Glycemic Control In Elderly Adults

Running head: GLYCEMIC CONTROL AND DEMENTIA IN ELDERLY POPULATION
Glycemic Control and Dementia in Elderly Population
Farzaneh Raoufi
Samuel Merritt University
Epidemiology and Population Health
N703
Karen Wolf, Ph.D.
April 13, 2013
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GLYCEMIC CONTROL IN ELDERLY POPULATION
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Abstract
Management of diabetes and glycemic control in general population, particularly in
elderly adults is costly and difficult due to complexity and comorbidity associated with diabetes.
People with diabetes are twice at risk for death in comparison to adults without diabetes (Centers
for Disease Control and Prevention [CDC]). Glycemic control in elderly adult aged 65 years or
older is crucial, as incidences of hypoglycemia may result in vision impairment, altered mental
status and other health related issues. Diabetes type 2 is associated with “1.5-2.5 fold increased
risk of dementia” (Strachan, Reynolds, Marioni, & Price, 2011). The purpose of this paper is to
establish whether or not hypoglycemia is associated with the development of dementia in elderly
population, aged 65 years or older with diabetes type 2.
Introduction
Diabetes is considered to be the “seventh leading cause of death” in the United States.
Approximately, 10.9 million of U.S. adult population aged 65 years or older had diabetes in 2010
(CDC, 2011).
From 2006 through 2009, the number of Emergency Department (ED) visits related to
diabetes was increased by about 10,528,000. From 2005 through 2008, results of fasting blood
glucose and hemoglobin A1c indicated that 50 percent of adults aged 65 years or older were
considered to be pre-diabetes (CDC, 2011). In the United States, diabetes is the leading cause of
renal insufficiency, below knee amputation and blindness. In addition, diabetes is the “major
cause” of cardiovascular disease and stroke. Cost of medical care related to diabetes is high and
will continue to rise. In 2007, the estimated “direct medical cost” related to diabetes was $116
billion (CDC, 2011).
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It is estimated that about half of elderly adults with diabetes do not know that they have
the disease. Due to “physiological changes associated with aging”, the signs and symptoms of
diabetes are masked in the elderly population. Often, elderly adults with diabetes present with
altered mental status, disorientation and incontinence.
Due to an “enhanced epinephrine
response”, elderly adults have severe hypoglycemia (Chau, & Edelman, 2001). In 2011, 28.5
percent of adults aged 65 years or older reported “poor mental health at least one day in the past
thirty days” (CDC, 2011). Therefore, glycemic control in elderly adult is highly desirable and
would reduce the incidences of confusion, dehydration and other symptoms or diagnoses
associated with diabetes.
Literature Review
One of the potential complications associated with diabetes is hypoglycemia.
Hypoglycemia is defined as “all episodes of an abnormally low plasma glucose concentration
that expose the individual to harm” (Services, et.al, 2012, para. 1). In a “longitudinal cohort
study from 1980-2007”, 16,667 elderly patients with the following criteria were screened for
hypoglycemia: a. diagnosis of diabetes type 2 and b. were a member of Northern California
Kaiser Permanente (Whitmer, et.al, 2009, p. 1565). Participants’ mean age was 65 years old.
About 66 percent of the participants were white and 55 percent were male. From 1980 through
2002, hospital discharges and ED diagnoses were utilized to collect and analyze the
hypoglycemia episodes. “Cohort members”, who had no history of dementia, or memory and
cognitive impairments “as of January 1st, 2003, were followed up for a dementia diagnosis
through January 15th, 2007” (Whitmer, et al., 2009, p. 1565). During follow up: a. 1465 of the
participants had one episode of hypoglycemia, b. 1822 patients had dementia, and c. 250 patients
had both one episode of hypoglycemia and dementia. Adjusted “hazard ratio” (HR) and “95
GLYCEMIC CONTROL AND DEMENTIA IN ELDERLY ADULTS
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percent confidence interval” (CI) for participants with” a. one hypoglycemic event were 1.26 and
1.10-1.49 (HR: 1.26, and CI: 1.10-1.49), b. two hypoglycemic events were 1.80 and 1.37- 2.36
(HR: 1.80 and CI: 1.37-2.36), and c. three or more hypoglycemic events were 1.94, and 1.422.64 (HR: 1.94 and CI: 1.42-2.64) (Whitmer et al., 2009, figure 3). The results of this study
indicated that elderly population with diabetes type 2 and hypoglycemic events were linked to
being at a great risk for dementia. The strengths of this research study were: a. inclusion of a
large cohort of participants of elderly adults of aged 65 years or older with diabetes type 2, and b.
participants had no prior history of dementia. The weaknesses of this study are: a. dementia
diagnosis was obtained from retrospective medical chart review and neurological assessments
were not utilized to validate the diagnosis, and b. majority of the subjects were women and
white.
Glycemic control in elderly population is complicated due to the presence of
comorbidities and other aged related risk factors. In a study conducted in Taiwan, one million
participants were randomly chosen from the “National Health Insurance Research Database”
(Lin & Sheu, 2013, p. 103). Total of 15,404 participants; “more likely women”, with the
following criteria were included in the study: a. diabetes type 2 diagnosis and b. no prior history
of dementia. The mean age was 64.2 years. The participants were followed up for a period of
seven years. Approximately, 289 participants had at least one episode of hypoglycemia in a
three year period of time. 1106 of the subjects were diagnosed with dementia. The incidence
rate of dementia for those with hypoglycemic events was 29.9 “per 1000 person-years” in
comparison to those without hypoglycemic episodes with “11.1 per 1000 “per 1000 personyears.” The results of this study indicated that elderly population with diabetic type 2 and
episodes of hypoglycemia were at higher risk for developing dementia (Lin & Sheu, 2013,
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p.104). The strength of this study was inclusion of a large number of participants. The
weaknesses and limitations of the study were: a. majority of the participant were likely women,
and b. the episodes of hypoglycemia were only followed for a period of three years.
In the “developed country”, the number of elderly adults with diabetes will increase from
25 million to 48 million. This increase can be due to lack of physical activity, obesity and fast
food and poor nutrition (Strachan, et al., 2008). In a study conducted in China, 8,213 subjects
aged 65 years or older participated. 1,109 participants with diabetes type 2 were selected via
interview and glucose testing. All participants were “screened with the DSM-IV criteria for
dementia” (Fei, et.al, 2013, para. 2). Cognitive and neurological assessments were completed for
all participants. 132 were diagnosed with “all cause dementia” with a prevalence rate of 1.61%.
The results of the study supports the fact that hypoglycemia was linked with dementia in Chinese
elderly population, aged 65 years or older with diabetes type 2 (Fei, et al, 2013). The strengths
of this study were: a. inclusion of a large number of participants, and b. comprehensive
neurological and cognitive assessments were utilized for screening dementia. The weakness of
the study is that age and gender of the participants were not included in the study.
Barriers to change
Monitoring of blood glucose is the ideal method for “achieving glycemic goal.”
“Physiological changes associated with aging”, the signs and symptoms of diabetes are masked
in the elderly population (Chau, & Edelman, 2001). Generally, hemoglobin A1c is monitored: a.
two times per year for elderly adults with “stable glycemic control,” and b. every three months
for elderly with fluctuating and unstable glycemic control (McCulloch, et al., 2013). Blood
glucose can be easily monitored by patients or caregivers at home. “Self-monitoring of blood
glucose” (SMBG) is beneficial in elderly patients with diabetes type 2 in order to avoid
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occurrences of hypoglycemic events (McCulloch, et al., 2013). However, compliance and
adherence to monitoring, treatment and follow-up may be a challenge in elderly population due
to cognitive impairment.
Gaps
Elderly population with diabetes type 2 may benefit from “health management support
system”, in which the results of blood glucose are either manually entered in a “personal digital
assistant” (PDA) or the results are digitally recorded and send to the primary care provider. The
physician may access and monitor patients’ results and provide instructions to the patients (Tani
et al., 2010). To evaluate use of a PDA, twenty volunteers from a corporation, “whose age’s
ranged from twenty to sixty,” responded to a survey questionnaire utilizing a PDA. The
evaluation of the results indicated that feedback from participants (Tani et al., 2010). Although,
advances have been made in this field, much improvement is needed, particularly for patients
with vision impairment or language barrier.
Diabetes in the United States
Diabetes is considered to be the “seventh leading cause of death” in the United States.
In the United States, diabetes among people aged 18-79 has been on rise from 1980 through
2010. About 63 percent of U.S. adults aged 18-79 were diagnosed with diabetes in 2011.
Approximately, 21 percent of diabetes diagnosis in 2011 was among elderly adults aged 65-79.
In 2011, “the median duration of diabetes” among elderly adults aged 65-79 was 9.8 years. In
2011, Diabetes was 25 percent higher among African American males and females and Asian
males, who were 65 years or older (CDC).
Age, Gender and Race
The table below presents the prevalence of diabetes among U.S. population (CDC, 2011).
GLYCEMIC CONTROL AND DEMENTIA IN ELDERLY ADULTS
Category
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Number of people with diabetes
People aged 20 years or older
25.6 million
People aged 65 years or older
10.9 million
Men
13.0 million
Women
12.6 million
“Non-Hispanic White”
15.7 million
“Non-Hispanic White”
4.9 million
Trends
Population of elderly is on rise and it is expected that population of people aged 65 or
older will increase by about 134 percent over the next thirty years ((Strachan, et.al, 2008). It is
estimated that about 2.8 percent of the “global population” (171 million people) have diabetes. It
is expected that about 4.4 percent (366 million people) of the world’s population will have
diabetes by 2030 (Strachan, et.al, 2008, para. 1).
Future Directions and Limitation
Glycemic control in patients with diabetes is the gold standard and would minimize the
risks associated with hypoglycemia. Elderly adults with diabetes type 2 are particularly sensitive
to low blood glucose level and may suffer from cognitive impairment and dementia. Cognitive
assessment along with blood glucose monitoring can be achieved via PDA. In a study done by
Onoda, et.al, 2013, use of PDA was found to be helpful in screening of dementia in Japanese
population. However, much advancement in the electronic medical record and PDA are needed
to ensure that: a. patient privacy is safe-guarded and b. PDA features are user friendly.
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Summary and Conclusion
The “prevalence of diabetes type 2” continues to rise, particularly among age group 6074 years old (McCulloch, et al., 2013). Achieving optimal glucose is crucial in the elderly
population as they are at risk for developing dementia. Based on the literature review of several
studies in this paper, there is a link between hypoglycemia and development of dementia in
elderly population aged 65 years or older, who have diabetes type 2. Most of the studies included
in this literature review, failed to include and demonstrate the effect of age, gender and race.
SMBG is beneficial in elderly patients with diabetes type 2 in order to avoid occurrences of
hypoglycemic events (McCulloch, et al., 2013).
Advancement in the electronic medical record and PDA will improve SMBG monitoring
in patients with diabetes. Advance practice nurses (APN) with informatics background can be
instrumental in reaching out and educating the elderly population with diabetes, who are
vulnerable and at risk for cognitive impairment. Future research studies are needed to examine
the effect of PDA and role of APNs in educating and assessing elderly patients with diabetes.
GLYCEMIC CONTROL AND DEMENTIA IN ELDERLY ADULTS
References
CDC. Retrieved from Centers for Disease Control and Prevention:
http://www.cdc.gov/diabetes/statistics/incidence/fig1.htm
CDC. Retrieved from Centers for Disease Control and Prevention:
http://www.cdc.gov/diabetes/pubs/pdf/ndfs_2011.pdf
Chau, D., & Edelman, S. V. (2001). Clinical management of diabetes in the elderly. Clinical
Diabetes, 19(4), 172-175. http://dx.doi.org/doi.10.2337/diaclin.19.4.172
Fei, M., Ping, Z. Y., Juan, M. R., Ning, L. N., & Lin, G. (2013, ). 1/7. Age Ageing.
http://dx.doi.org/doi: 10.1093/aging/afs188
Lin, C. H., & Sheu, W. H. (2013). Hypoglycaemic episodes and risk of dementia in diabetes
mellitus: 7 year follow-up study. Journal of Internal Medicine, 273(1), 102-110.
http://dx.doi.org/doi: 10.111/joim.12000
McCulloch, D. K., Munshi, M., Nathan, D. M., Schmader, K. E., & Mulder, J. E. (2013).
Treatment of type 2 diabetes mellitus in the elderly patient. Retrieved from
http://www.uptodate.com
Onoda, K., Hamano, T., Nabika, Y., Aoyama, A., Takayoshi, H., Nakagawa, T., Yamaguchi, S.
(2013, 3/26). Validation of a new mass screening tool for cognitive impairment:
Cognitive assessment for dementia, iPad version. Journal of Clinical Interventions in
Aging, 8, 353-360. http://dx.doi.org/doi: 10.2147/CIA.S42342
Service, F. J., Cryer, P. E., Hirsch, I. B., & Mulder, J. E. (2012). Hypoglycemia in adults:
Clinical manifestations, definition, and causes. Retrieved from http://www.uptodate.com
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GLYCEMIC CONTROL AND DEMENTIA IN ELDERLY ADULTS
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Strachan, M. W., Reynolds, R. M., Frier, B. M., Mitchell, R. J., & Price, J. F. (2008, 10/18). The
relationship between type 2 diabetes and dementia. British Medical Bulletin, 88(1), 131146. http://dx.doi.org/doi: 10.1093/bmb/dn042
Strachan, M. W., Reynolds, R. M., Marioni, R. E., & Price, J. F. (2011). Cognitive function,
dementia and type 2 diabetes mellitus in the elderly. Nature Reviews Endocrinology,
7(2), 108-114. http://dx.doi.org/doi: 10.1038/nrendo.2010.228
Tani, S., Marukami, T., Matsuda, A., Shindo, A., Takemoto, K., & Inada, H. (2010).
Development of a health management support system for patients with diabetes mellitus
at home. Journal of Medical Systems, 34(3), 223-228. http://dx.doi.org/doi:
10.2147/MDER.S28134
Whitmer, R. A., Karter, A. J., Yaffe, K., Quesenberry, C. P., & Selby, J. V. (2009, 4/15).
Hypoglycemic episodes and risk of dementia in older patients with type 2 diabetes
mellitus. Journal of American Medical Association, 301(15), 1565-1572.
http://dx.doi.org/doi: 10.1001/jama.2009.460