Download Diabetes in the Older Patient

Diabetes in the Older Patient
Debra Bynum, MD
Associate Professor of Medicine
Division of Geriatric Medicine
University of North Carolina
March 2010
True or False?
• 1. A healthy 90 year old woman is likely to live to
be 95…
• 2. Obesity is associated with increased mortality
in people over the age of 70
• 3. Patients over the age of 80 with systolic
hypertension should not be treated because of an
increased risk of falls
Outline
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Prevalence
Heterogeneity (Patients and Disease)
Specific complications
Diabetes and Geriatric Syndromes
Diabetes in the Frail
Obesity in the Older Patient
Treatment Basics
Take Home Points
Focus
• How is diabetes different in the older patient?
Prevalence
• Majority of patients with DM are over age 60
• >10% patients over age 65 have DM
• >10% over age 60 may have undiagnosed DM
• CDC estimates prevalence of DM: 23% (diagnosed
and undiagnosed) in people over 60
• Framingham Data: 40% those over 65 have DM or
Impaired Fasting Glucose
Heterogeneity: Patients
• Average Life expectancy 72-79
▫ At age 65, average life expectancy 82
▫ At age 85, average life expectancy 90
▫ Fastest growing population: over 85
• Differences
▫ Age (65, 75, 85, 95, 100)
▫ Frailty and age are not equal
▫ Associated co-morbidities
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
LADA
• Autoimmune (antibodies present at diagnosis)
• Resembles type I diabetes
• Later onset (after age 30)
• Slower progression toward absolute insulin
requirement (presentation with ketosis
uncommon)
Complications
Hyperglycemia
• Dehydration
▫ Increased risk in elderly
▫ Decreased oral intake, decreased thirst
mechanism
• Visual disturbance
• Confusion
Nonketotic 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
• Higher mortality
• Older patients with dementia, decreased access to free
water (nursing care setting), and decreased thirst are at
higher risk
Hypoglycemia
• 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
Hypoglycemia
• Risk 2-9% in cohort studies
• ?association with later development of dementia
▫ Cohort study of patients followed over 20 years
▫ Patients with at least one episode of severe
hypoglycemia had increased risk of development
of diabetes
▫ May be confounder and not causal…
 JAMA 2009
Nephropathy
• Overall increase 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
Renal Insufficiency
• “Normal Creatinine” may not be normal
▫ Calculate GFR
▫ GFR depends upon age, weight, sex
▫ Creatinine of 1.1 in an 80 pound woman who
weighs 98 pounds is not “normal”
Visual Loss
• Often multifactorial
• Retinopathy often less progressive than in
younger patients with DM
• Glaucoma three times more common in older
patients with DM (11% vs 4%)
• Cataracts more common and more rapidly
progressive
Foot Care
• Neuropathy
▫ Common and not always due to DM in older
patients (50% patients over 80 have peripheral
neuropathy)
▫ 1/3 older patients cannot see/reach feet
Foot Care
• Elderly with DM high risk for infection,
cellulitis, ulcers, gangrene and amputation
• Cohort study of patients over 10 years, average
age 75, from Archives Int Med, 2007:
▫ 19% DM group had episode of gangrene
▫ 3% DM group had amputation
Cardiovascular Risk
• Challenges:
▫ Most older patients with DM will die of CV disease
▫ Treatment-Risk Paradox
 Older patients have high risk of CV disease
 Even small potential decrease in risk of disease could
have big benefit and be work risk of treatment
▫ No evidence to suggest that control of diabetes
results in less CV risk
CV Disease: Modification of Risk
Factors
• Evidence that older patients with DM and CVD
and hyperlipidemia benefit from treatment with
statins (similar to/better than younger
population)
• Recent studies also showing no additional
benefit to “tight” control
CV Disease: Modification of Risk
Factors
• Evidence from multiple large studies (SHEP,
Syst-Eur) that older patients with Systolic
Hypertension benefit from treatment
▫ Decrease stroke
▫ Decrease CHF
• HYVET:
▫ Patients over age 80 benefit with decrease stroke,
CHF, and mortality
Hypertension in Older Patients
• Keys from studies:
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Treated Systolic Hypertension
Target SBP 150
Followed standing blood pressures
Benefit seen even though significant number of
patients did not even reach target SBP of 150
▫ Take Home: Moderate SBP reduction in
the very elderly can have significant
benefit!
Complications: Geriatric Syndromes
• Older patients with DM also more likely to have:
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Falls
Sarcopenia/muscle wasting
Malnutrition
Depression
Dementia
Urinary Incontinence
Diabetes in the Frail
• More modest goals in BP and glucose control
• Balance quality if life
• Observe for other risks
▫ Ulcers (heel and sacral)
▫ Malnutrition
▫ dehydration
Obesity
• Modest overweight (BMI 25-30) associated with
LESS mortality in older people
• Likely association with increased mortality when
BMI over 30
• Conflicting studies with association between
weight loss and increased mortality
Obesity
• BMI does not perform well in older patients
(increased body fat for same weight as we age)
• Waist circumference has greater prognostic value
than BMI in older patients
• Weight loss can be associated with loss of muscle
and risk of malnutrition in older patients
• Almost impossible to tease apart possible
underlying disease and weight loss in patients over
age 70
Dietary Restrictions
• No evidence to suggest dietary restrictions in
frail elders
• Balance other concerns:
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Quality of life
Malnutrition
Vitamin deficiencies (D)
Risk of fracture
Depression
Chewing/dental problems
Treatment
• Treatment options usually similar, balance comorbidities, frailty, and life expectancy
• Target systolic hypertension and hyperlipidemia
▫ No evidence to suggest “tight” control
▫ Modest treatment does have benefit at CV risk
reduction in older patients: do not avoid treatment
based upon age!!
• No evidence to suggest tight control of DM
▫ Goal Hgb A1C 7-8% suggested
▫ Recent ACCORD data supports this
Treatment
• Must take into account functional status and
caregiver/facility status
▫ Consideration of insulin and glucose monitoring
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?caregiver help if needed
Vision
Arthritis of hands
Cognitive status
▫ Treatment in some cases easier in nursing care
facility
▫ Do not avoid treatment in functional, independent
patients or in those with needed support
Take Home Points
• Older patients with DM differ in many ways
• Treatment of DM relies upon treatment of the individual
• Do not avoid treatment in older patients based upon age
▫ Older patients with have higher risk of bad outcomes
▫ Modest treatment benefit significant the high risk
• Consider goals of treatment and balance: BP, glucose,
weight and lipid reduction goals should be MODEST
Questions and Discussion