Download diabetics

Who is considered elderly?

“Young old” 65-75 years

“Old, old” >75 years
Why does Diabetes increase
with Age?
• Changes in insulin secretion, action and
hepatic glucose production with aging
• Genetic predisposition
• Medications that may change glucose
metabolism (?thiazides?)
• Older patients more likely to be “lean”
diabetics: more problem with insulin
secretion than insulin sensitivity as seen
in obese, middle aged diabetics
• Latent Autoimmune Diabetes of Adults:
LADA
• Even healthy elderly individuals :age-related
increase in fasting blood glucose (1 mg/dL
per decade) .
• And increase in blood glucose (5 mg/dL per
decade) in response to a standard glucose
tolerance test.
•
Nearly 10% of the elderly have some degree
of glucose intolerance.
• Most diabetes in the elderly is type 2
diabetes
• Diabetes may be difficult to diagnose in the
elderly
because of its often atypical
and asymptomatic
presentation.
Signs and symptoms of Type 2
Excessive urination
 Thirst
 Recurrent infections / Thrush
 Tiredness / Drowsiness
 Weight change
 Blurred vision
 Hyperglycaemia
 Dehydration
 Urinary ketones
 Glycosuria

• ADA criteria are NOT adjusted
for age
Case detection and diagnosis

Asymptomatic elderly people should
be screened for undiagnosed
diabetes by measurement of
fasting plasma glucose as
recommended for the general
population
Screening Review
• >45 and older every 3 years,
• Risk factors:
• Family history of coronary heart disease,
• Cigarette smoking
• Hypertension
• Obesity
• Kidney disease
• Dyslipidemia.
Aging and Diabetes
• Poor diabetes control exacerbates the
aging process.
•
Poor diabetes control causes age related
disease to develop earlier.
• Poor diabetes control makes co – morbid
conditions worse and harder to manage .
Treatment Recommendations
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Glycemic Control
Hypertension
Lipids
Tobacco cessation
Eye care
Foot care
Nephropathy
Diabetes Self-Management Training
Treatment goals for diabetes
Symptom free
 Prevent short term
complications
 Prevent long term
complications
 Quality of life =Lifestyle focus

Treatment Options
• Individualized
• Weigh risks of hyperglycemia with hypoglycemia
• No data that tight control prevents stroke or
cardiovascular events or improves mortality in this
age group
• Consider cost of medications, limited coverage
• Risk of “polypharmacy”, increased risk of side
effects and drug-drug interactions
• Treatment must be practical: are there functional
limitations that will make plan of care difficult
Guidelines focus

Guidelines focus on “healthy” person with
diabetes over the age of 65 years

Needs of “frail” elderly should be
considered on individual basis with special
consideration of physical and mental
status
Functional categories of older
people with diabetes
Category1:
Functionally independent
• This category is characterized by
people who are living
independently have no important
impairments of activities of daily
living (ADL ), and who are
receiving non or minimal caregiver
support
Category 2:
Functionally dependent
• This category represents those individuals
who, due to loss of function , have
impairments of ADL.
• This increases the likelihood of requiring
additional medical and social care .
• Such individuals living in the community are at
particular risk of admission in HOSPITAL
Category 3:
end of life care
• These individuals are
characterized by a significant
medical illness or malignancy and
have a life expectancy reduced to
less than 1 year

Controlling blood
glucose levels
 Healthy Eating:
 Regular
carbohydrate
 High in fibre
 Low in fat
(particularly
saturated fat)
 Low in added
sugar
 Adequate
energy
/protein/fluids/
vits and mins
Special treatments

Nutrition assessment
Distribution and intake of
carbohydrate important
 Weight loss not recommended unless
> 20% above weight range

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Encouraged to follow National
Physical Activity Guidelines: 30
minutes of physical activity each
day (tailored for frail elderly)
Recommendations :General
• Glycaemic control targets should be
individualized taking into account functional
status ,comorbidities , history and risk of
hypoglycaemia , and presence of
complication .
• Begin oral glucose lowering therapy when
lifestyle interventions alone are unable to
maintain target blood glucose levels .
• Use the “start low and go slow ” principle in
initiating and increasing medication and
monitor response to each initiation or dose
increase for up to a 3 month trial period .
• Consider discontinuing ineffective and
unnecessary therapies .
• Consider the cost and the risk- to – benefit
ratio when choosing a medicine
• Lifestyle intervention is preferable to
treatment with metformin in reducing
the
risks of type 2 diabetes In non – obese
older
adults with elevated fasting and
postload
plasma glucose levels
• Metformin should normally be first line
therapy for overweight older adults with
type2 diabetes.
• In non- obese older people with diabetes
first line therapy with an insulin
secretagogue (normally a sulphonylurea ) or
metformin should be offered
• Glibenclamide should be avoided for newly
diagnosed cases of type 2 diabetes in older
adults (>70 years ) because of the marked risk
of hypoglycaemia.
Less risk :Glipizide , Glimepride.
• A DPP-4 inhibitor as an add-on to metformin
when use of a sulphonylurea may pose an
unacceptable hypoglycaemia risk can be
considered in an older patient with diabetes.
• When oral agents fail to lower glucose
levels adequately , insulin may be given
either as monotherapy or in combination
with a sulphonylurea or metformin .
• Use of a long – acting insulin analogue
(e,g,glargin, determir ) rather than NPHinsulin should be considered in older
patients
If Choosing To Use Insulin---
Glargine (lantus) insulin
• Long acting
• Often fear of hypoglycemia because long
acting, especially in patients with renal
insufficiency or unreliable po intake
• But studies demonstrating less risk of
hypoglycemia, especially in patients with
“brittle” diabetes and nocturnal hypoglycemia
Risks Of Intensive Glycemic
Control
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Hypoglycemia
Polypharmacy
Drug to drug interactions
Drug to disease interactions
In conclusion the aim in elderly
people with diabetes is to
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Relieve symptoms of high glucose
levels
Avoid low glucose levels
Achieve agreed blood glucose levels
Monitor diabetes complications
Encourage health and fitness habits
Ensure older people are actively
involved in setting goals for their
diabetes management