Download Diabetes and The Older Patient

Diabetes and The Older
Patient
Debra L. Bynum, MD
Division of Geriatric Medicine
Objectives
• 1. Review treatment options in caring for older
patients with diabetes
• 2. Understand risks of hyperglycemia and
hypoglycemia in older patients
• 3. Appreciate importance of cardiovascular risk
reduction in older patients with diabetes by treating
hypertension and hyperlipidemia
• 4. Gain awareness of association: diabetes, HTN,
and vascular risk factors with dementia
• 5. Discuss the Treatment-Risk Paradox and how this
applies to medical management in older patients
Outline
• Prevalence
• Acute complications
• Treatment options and goals
• Risks of longstanding diabetes
• Reducing cardiovascular events: treating
hypertension and dyslipidemia
• Dementia: association with cardiovascular risk
factors; ?can we prevent it?
• The Treatment-Risk Paradox: Paper review
Cases
Case Study #1
• 78 y/o nursing home resident presents for
evaluation of recurrent severe hypoglycemia.
Diagnosed age 65 , treated with sulfonylurea
without response, subsequently treated with
insulin, currently 70/30 14 u in AM, 10 u QHS.
Logs: 4-6 readings/day, ranging from 30’s
(usually in afternoon or early AM) to mid 500’s,
average 195.
• PE: 61”, 98 lbs, 138/66, 82. Exam unremarkable
A1c=8.6%; Creatinine=1.3, TC=150, HDL=70,
LDL=70, TG=50
Case 1:
• Does this patient have type 1 diabetes?
Case study #2
• 92 year old woman comes to you on
glyburide at 10 mg a day. She, after
much discusssion, is unable to check
her own glucose. She is very afraid of
having a hypoglycemic reaction as she
lives alone. Her Hgb A1C is currently
9.8%. She is otherwise healthy, on no
other medications, and is completely
active and independent.
Case # 2
• What is the goal of treatment in this woman?
• What are the risks and the benefits of “tight”
control for this patient?
• What should her goal A1C be?
• Describe some barriers to self monitoring for
older patients.
• Is Metformin contraindicated?
Case # 3
• You are following a 75 year old woman
in the nursing home who has a severe
dementia that is probably mixed
alzheimers/vascular type, complicated
by diabetes, hypertension and
hyperlipidemia.
• PE: weight 95 lbs
Case # 3…
• How tight should control be for this patient?
What would be an optimal HgbA1C?
• How should her diet be managed? Is there
any evidence for dietary restrictions in this
setting?
• What are the risks and benefits of optimizing
her blood pressure control?
Case # 4
• A healthy, active, independent 85 year
old woman with DM presents to you for
care. She is concerned because her
sister has a severe dementia. Other
than a blood pressure of 170/70, her PE
is unremarkable.
Case study 4
• Is her risk of dementia higher with an
underlying diagnosis of diabetes?
• What is the significance of isolated
systolic hypertension in the elderly?
Should this be treated?
• What is the average life expectancy of a
healthy 80 –85 year old woman?
Some Numbers…
• Aging of America
–
–
–
–
Average life expectancy 72-79
At age 65, average life expectancy 82!
At age 85, average life expectancy 90
Fasting growing segment: over 85
• 1.5% population
• Almost 5% of population by 2050
• Prevalence of Diabetes
• Prevalence of Cardiovascular disease
• Prevalence of Dementia
Some Numbers…
• Aging of America
• Prevalence of Diabetes
– Over 20% those over 65 (NHANES 1994)
– Framingham Data: Diabetes or impaired glucose tolerance
(fasting glucose 120-139) in nearly 40% those over 65
– Over 65 account for over 40% diabetic population
• Prevalence of Cardiovascular Disease
• Prevalence of Dementia
Some Numbers…
• Aging of America
• Prevalence of Diabetes
• Prevalence of Cardiovascular Disease
–
–
–
–
Heart disease and stroke: Leading causes of death
60% deaths in those over 85 due to CVD
Morbidity: stroke and CHF
CHF: 6% new diagnoses/per year in age over 85
• Prevalence of Dementia
Some Numbers…
• Aging of America
• Prevalence of Diabetes
• Prevalence of Cardiovascular Disease
• Prevalence of Dementia
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–
–
–
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6-10% those over 65
30-50% those over 85
Nearly 70% in those over 95
By 2025, expected 2 million centenarians in US!
Leading public health concern as the new chronic
disease…
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
What are the risks of Diabetes
in the older patient?
• Number 1: Cardiovascular disease
• Nephropathy
– Increasing importance of ESRD in older patients
• Neuropathy
• Retinopathy
• Problems with Feet
• New directions:
– Dementia
– Marker of bad outcomes
• Hyperglycemia bad predictor in those admitted with stroke and
other acute illnesses
Diagnosis of Diabetes
• ADA criteria are NOT adjusted for age
• FPG >= 126
• Impaired Glucose Tolerance: glucose
100-125
Impaired Glucose Tolerance…
• Occurs in 25% of older patients
• Increases risk for development of diabetes
• Longitudinal study of older patients: those with Impaired
Fasting Glucose had slightly increased risk of cognitive
impairment and dementia compared to those with
normal glucose
• Lifestyle modification can decrease risk of developing
diabetes
Short Term Complications
• Hyperglycemia
• Hypoglycemia
Hyperglycemia
• Dehydration
– Increased risk in elderly: decreased intake,
decreased thirst mechanism
– Falls, confusion
• Visual disturbances
– Significant hyperglycemia distorts lens, visual
blurring
• Confusion
Nonketotic Hyperglycemic
Hyperosmolar Coma
• More common than DKA in older patients
• Higher mortality
• Usually associated with severe dehydration,
infection, myocardial event, stroke, acute
stress
• Precipitating factors: dementia, decreased
access to fluid, decreased thirst mechanism
Hypoglycemia
• Risk factors:
– Older patients
– Renal insufficiency
• “normal” creatinine means less: glomerular filtration rate
is NOT normal in 90 year old woman who weighs 85 lbs
with creatinine of 1.1
– Long acting oral agents
• Especially in those with renal insufficiency
– Poor nutrition
• Decreased muscle mass and poor glycemic reserves
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–
–
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Alcohol use
CHF
Post hospitalization
Polypharmacy
Pearl
• Calculate GFR in older patients:
“normal” creatinine may NOT be
normal!!!
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
Treatment Options: Some
Comments….
Treatment options overall similar in older
patients
Special notes:
beware renal function
beware polypharmacy and risk of drug
interactions
beware risk of interactions with other
comorbidities (CHF, dementia)
Treatment Options: Most
common…
• Sulfonylureas
– Stimulation of insulin secretion
– Increased risk of hypoglycemia in elderly, esp
with renal insuff
– Less risk: glipizide (glucotrol), glimepride
(amaryl);
– Higher Risk: glyburide (diabeta, micronase)
metformin
•
•
•
•
•
•
Biguanide
Decrease hepatic glucose production
Low risk for hypoglycemia
Side effects: gi
Risk: lactic acidosis
Not in women with creat over 1.4, men over
1.5, OR creat clearance < 60
• NOT absolute contraindication with age, but
beware of renal function
Thiazolidinediones
•
•
•
•
•
•
Improving insulin sensitivity
Rosiglitazone (avandia)
Pioglitazone (actos)
Do not cause hypoglycemia
Weight gain, fluid retention
Contraindicated with severe heart
failure
Insulin
• May be best option
• Can the patient do it?
– Dementia
– Caregiver
– Vision
– Arthritis
• Likely underutilized due to fear of
hypoglycemia…
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
Treatment Goals
•
•
•
•
Individualized
No data for tight control…
Most recommend Hgb A1c 7-8%
Other options:
– Tight control: healthy “young” older patients (lifespan
20years) to decrease risk nephropathy, retinopathy
– “permissive”: those with advanced illnesses, terminal
illnesses; goal more to prevent severe hyperglycemia and
avoid hypoglycemia; goal glucoses 200 range
Treatment Goals
• Endocrinology, General Internal Medicine/Family
Medicine or Geriatrics?
• Geriatricians see older patients with dementia;
Endocrinologists use more complicated regimens
and care for slightly younger patients and/or those
with microvascular complications
• ALL have lower than advised rates of screening for
diabetic complications, adequate treatment of
hypertension and hyperlipidemia, and goal AIc–
• is this bad? Don’t know….
Some special circumstances
• Tube feeding
– Increases hyperglycemia
– Specialized formulas
– Acute setting: continuous insulin, BID
NPH, Q6 Reg
– Long term: basal insulin with glargine;
with bolus feeds, consider short acting
insulin prior to bolus
Special Circumstances…
• Type 1 diabetes
– Decreased beta cell function with aging
– More common in younger patients but can occur
in older patients (10-15% of elderly patients with
diabetes have evidence of autoimmunity)
– “latent autoimmune diabetes of adulthood”
– DKA
– “brittle” with episodes of hypoglycemia
– First case…
Nursing home setting
• Risk of ulcers (heel and sacral)
• Risk of dehydration
• Little to support dietary restrictions in frail nursing
home elders
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–
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Quality of life concerns
Risk of malnutrition
Anorexia/depression
Chewing/dental problems
– 2001 study found no difference in glycemic control in
patients on restricted diet compared to those on regular diet
with more emphasis on pharmacologic control
Nephropathy
• Previously no recommendation to screen for
microalbuminuria if normal renal function
– Lower risk of ESRD in older patients with DM
– Long interval between presence of albumin and
ESRD….
• Current AGS and ADA guidelines recommend
annual check for microalbumin
– Lifespan of 70 year old is 10 years or more
– ESRD increasing prevalence in elderly with more
older patients on dialysis…
– Marker of increased stroke and CVD risk in
addition to nephropathy in older patients
Vision…
• Retinopathy
– Prevalence in older patients with DM seems to be
less and overall less progressive disease than in
younger patients with DM
• Glaucoma
– Three times more common in older patients with
diabetes (11% vs 3.8%)
• Cataracts
– More common in older patients with DM (38% vs
16%)
– Association with more rapidly progressive
posterior capsule cataracts …
Neuropathy
• Very common
– Over 50% in those over 80
• Not always due to Diabetes
• 1/3 older patients cannot see/reach feet
• Importance of caregiver education
Special Population: The FRAIL
• Not all older patients are FRAIL
• Frailty as increasingly recognized diagnosis
• Features:
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Functional decline
Sarcopenia
Weight loss
Associated diseases such as Diabetes
Stressors that precipitate
• Hip fractures, pneumonia, depression, stroke
Treatment of the Frail
• Care with any dietary restrictions
• Significant number nursing home residents
with weight loss, at risk for malnutrition
• Tight control likely not goal
• Still consider treatment of cardiovascular
risk factors to reduce risk of CHF, stroke and
morbidity
Big Goal: Prevention of
Cardiovascular Events…
• Common diseases: Diabetes, Hypertension,
Hyperlipidemia
• Common outcomes: Stroke, CHF/CAD, Dementia
• No evidence that aggressive treatment of DM
prevents/ changes these outcomes, but DM often
seen in patients with HTN and hyperlipidemia, and
mounting evidence that treatment of these risk
factors can modify the risk of CAD, CHF, stroke and
possibly even dementia in this group
Diabetes: CV equivalent
• Patients with type 2 diabetes without prior hx
of heart attack have same risk of MI
compared to patients with prior hx of MI
• Therefore, treat patients with DM as
aggressively as secondary treatment in
patients with known CVD
• ?age as new “CV equivalent”
• Bad combination: DM and older age!!!
Hypertension and
Hyperlipidemia
• Treatment of hypertension and
hyperlipidemia reduces CV outcomes
• Biggest bang for the buck: treating in
High Risk Groups
• Higher benefits in those with diabetes
and advanced age
Hypertension
• Hypertension is very common in older
patients, mainly due to Systolic
Hypertension (SH)
– Hypertension seen in 60% those over 65
– 75% hypertension in older patients =SH
– JNC definition: SBP >160, DBP <90
– Pulse Pressure: SBP – DBP
• Higher (over 50) due to stiff arteries
• SBP and PP MORE predictive of stroke and CV
events in older patients
Hypertension
• Multiple large randomized controlled
trials have demonstrated significant
benefit in treating Systolic
Hypertension in older patients
– SHEP
– SYST-EUR
– SYST-CHINA
– SCOPE
Systolic Hypertension
• Treatment of SH in older patients:
– Decreased risk of stroke
– Decreased risk of CHF
– Decreased combined endpoint of all CV events
(CHF, stroke, CAD, mortality)
– Larger benefits seen in patients with diabetes…
Treatment of Hypertension
• Choice of agents:
– Thiazide diuretics (HCTZ, maxzide)
ALLHAT study: JUST AS EFFECTIVE AS THE MORE
EXPENSIVE, NEWER MEDICATIONS!
– ACE inhibitors, angiotensin II receptor blockers,
long acting calcium channel blockers
– Beta blockers
Systolic Hypertension and
Dementia…
• Epidemiological studies :association
between SH and dementia in older patients
• Surprise finding in SH trials
– Patients in treatment arms of trials had reduced
risk of dementia at follow up (4 years) compared
to those in placebo group
– Two surprises:
• Those in placebo group, even after trial ended and
started on antihypertensive treatment, STILL had
increased risk of dementia
• Risk of Vascular AND Alzheimer dementias were
increased!
Dementia
• Systolic Hypertension and Diabetes
seem to be independent risk factors for
dementia
– Vascular dementia and alzheimer type
– SH, DM, and dementia all more common
with aging: a difficult web to untangle…
– But dementia seems to be related to or
worsened by traditional cardiovascular
risk factors…
Treatment of SH: Summary
• Treatment of SH in older patients decreases the risk
of stroke, CHF, and combined CV events
• Evidence that treatment of SH prevents dementia…
• Aging, HTN and DM HUGE risk for CVD
• Treatment of CVD risk factors such as HTN critical
treatment of older patients with DM
• Thiazide diuretics cheap and effective in older
patients
• Multiple therapeutic options
Hyperlipidemia
• Previously many older patients not treated
– Thought that statin agents took years to have
effect, and those over age 70 would not benefit
– Often cited “lack of data” in older group
– Worry about increased risks
• But…
– Newer evidence that statin agents work short term
– Newer thoughts about average lifespans…
– Lack of data due to prior studies excluding older
patients, not due to lack of observed benefit in
trials…
– So far, increased risks of rhabdo and liver disease
have not really panned out in older patients
Hyperlipidemia
• More studies now addressing treatment of
hyperlipidemia in older patients
• CARE trial: diabetic patients with LDL <130 benefited
from statin agents to further reduce cholesterol,
regardless of age
• PROSPER study (Lancet 2002): Pravastatin given for
3 years reduced CVD risk in elderly
• Heart Protection Study: those over 75-80 had a
GREATER reduction in cardiovascular events (29%)
compared to the younger patients in the trial (25%)
Summary of studies…
Hyperlipidemia
• Given fact that older patients have much
higher risk of CV events, then the same
relative risk reduction by treating this group
may have overall GREATER absolute risk
reduction
The Treatment Paradox
• BUT, is this group at increased risk for
complications?
– The treatment paradox… to be discussed
Hyperlipidemia
• Treatment groups:
– Older patients with DM
– Older patients with prior CV event (stroke,
MI, CHF)
– All older patients with hyperlipidemia?
• Patients over age 70 should be considered very
likely to have underlying CAD/CVD (much as
those with diabetes): the new Cardiovascular
equivalent
Treatment of Hyperlipidemia:
summary
• Aging as a “cardiovascular” equivalent; Aging and
DM as major risk factors for CVD
• Treatment of hyperlipidemia in older patients is well
tolerated
• Treatment of hyperlipidemia in older patients has
similar/better reductions in CV events as in younger
patients
• Given the increased risk of CV events in this group,
the potential benefit may be greater
• Benefit may be in reduction of CV events, CHF,
stroke, and possible dementia; mortality benefit not
clear
Further Management…
•
•
•
•
•
Smoking cessation
Weight loss
Dietary changes
Exercise
Daily ASA
Summary Guidelines for care of
older persons with Diabetes:
AGS 2003
Aspirin
Recommended if no other anticoagulant and
no contraindications
Smoking cessation
Recommended
Hypertension
Target <140/80 (<130/80) as tolerated
Lipids
LDL <100
Control
A1c <7% in healthy with good functional
status; <8% in frail elders with life expectancy
<5 yr or when risks of tight control outweigh
benefits
Monitoring
A1c every 6 mo if not at goal; every year if at
goal; create individual plan for self monitoring
Hypoglycemia
Referral, contacts
Dilated eye exam
Time of dx and annually for those at risk,
every 2 yr for those at low risk
Foot care
Annual screening
Microalbumin
Dx and annually
Screening
Depression, cognitive impairment, falls, pain,
urinary incontinence, polypharmacy
Summary Points
• Not clear that tight control of glucose is of great
benefit in older patients
• Diagnosis and treatment options are not really
different
• Avoidance of hypoglycemia and severe
hyperglycemia are important
• Care in older patients must include consideration of
Functional Status
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Cognition
Physical ability (vision, arthritis)
Social support
Financial support
Summary Points…
• DM and HTN are traditional risk factors for CVD
• Aging, like DM, as “cardiovascular equivalent”,
older patients have HIGH risk of underlying CVD
• Older patients with DM and HTN die of CVD and
suffer morbidity from strokes and CHF
• Dementia is probably related to underlying CV risk
factors, with an increased prevalence in those who
– are older
– Have diabetes
– Have SH
• Treatment of CV risk factors may decrease the risk
of dementia
The Treatment-Risk Paradox
• What is it?
• Why is this important in the care of older patients?
• Why might older patients be “undertreated”?
• What types of processes might older patients be
“undertreated”
• Review of the Article: Lipid Lowering Therapy With
Statins in High Risk Elderly Patients; JAMA 2004;
291 (15) 1864-1870.
Paper: Background
• Multiple studies have shown inverse
relationship between treatment (variety of
illnesses) and age, even when evidence
supports use in older patients
• Concerns about quality of life, treatment
complications, interactions with other
medications or comorbidities
• We are taught the key to geriatrics: start low
and go slow….
But…
• Not all older patients are the same
• Age is more than number; physiological age may be
important
• Recognition of difference between life expectancy at
given age and average life expectancy at birth…
• Recognition that “Frail” patient is different than the
“robust” patient, regardless of age…
Study Design
• Retrospective cohort study
• Databases of over 1 million elderly in
Ontario, study looked at nearly 400,000
over age 66 with history of CV disease
or DM (SECONDARY PREVENTION)
• Outcome: likelihood of statin use for
each CV risk group
?Confounders?
• What are the potential “confounders”
for this type of study (what other
reasons other than age might account
for a difference in statin use….)?
Adjustments
• Adjusted for:
– Age
– Sex
– Socioeconomic status
– Rural or urban residence
Results
• Only 19% prescribed statins
• Likelihood of statin prescription was
6.4% lower for each year of increased
age AND each 1% increase in predicted
3 year mortality risk
Likelihood of statin prescription:
Ages 66-74
Low CV risk
(7.8% 3 year
mortality)
Intermediate
Baseline Risk
(12.8% 3 year
mortality)
High Baseline
Risk
(34.4 % 3 year
mortality)
37.7%
26.7%
23.4%
Likelihood of statin Rx: ages
75-80
Low CV risk
(13.7% 3 year
mortality)
Intermediate
risk
(21% 3 year
mortality)
High risk
(43% 3 year
mortality)
29%
19%
15%
Likelihood of statin Rx: age >
80
Low risk
(25% 3 year
mortality)
Intermediate
High risk
risk
(60 % 3 year
( 40% mortality) mortality)
13%
6%
4%
Results
• Patients prescribed statins: more likely
younger, men, history of angina/acute
MI/invasive cardiac procedure
• Patients not prescribed statins: more likely
to have DM, CHF, stroke and to live in rural
areas
• Lower use of statins in patients with higher
CV risk across full spectrum of CV risk and
across entire spectrum of age
Discussion:
• How to interpret these results?
• Caution?
• What is the risk of “undertreatment”?
“overtreatment”?