Diabetes and elderly

Challenges, Goals and Therapeutics in the Elderly

Dr.S.Venkatraman MD.,

Aging and Society2010 Projection

CountryUnder 15

yrs old65 yrs oldand over

Egypt 34.9 5.2

Ethiopia 60.3 3.6

France 18.0 17.3

Germany 14.3 20.1

India 33.6 6.1

Indonesia 31.9 6.7

Iran 28.5 5.3

Iraq 50.3 3.9

Italy 13.1 20.5

Japan 14.5 21.9

Kenya 38.0 3.7

2010 Projection

CountryUnder 15

yrs old65 yrs oldand over

World 30.0 8.6

Argentina 27.3 12.3

Australia 20.4 15.3

Bangladesh 34.5 4.5

Brazil 26.4 7.5

Cambodia 47.3 4.5

Canada 18.2 15.5

Chile 25.1 10.2

China 22.5 8.9

Colombia 33.1 6.6

Cuba 18.1 12.5Age Distribution by Country: 2010 Projection (in percent)

Source: U.S. Bureau of the Census. 2001. Statistical Abstract of the United States 2001. Washington, DC: U.S. Government Printing Office. Table 1328 on p. 834. Also accessible at http:www.census.gov/prod/2002pubs/01statab/stat-ab01.html.

High level of associated comorbidities Increased risk of cognitive dysfunction and mood disorder causing more complex decisio makingIncreased vulnerability to hypoglycaemiaAltered drug metabolism Unstructured specialist and primary care follow up Increased risk of inpatient mortality

1.What is the epidemiology and pathogenesis of diabetes in older adults?

2.What is the evidence for preventing and treating diabetes and its common comorbidities in older adults?

3.What issues need to be considered in individualizing treatment recommendations for older adults?

4.What current guidelines exist for treating diabetes in older adults?

5.What are consensus recommendations for treating older adults with or at risk for diabetes?






The incidence of diabetes increases with age until about age 65 years, after which both incidence and prevalence seem to level off.older adults with diabetes may either have incident disease (diagnosed after age 65 years) or long-standing diabetes with onset in middle age or earlier.

Aging and insulin secretion Am J Physiol Endocrinol Metab284: E7–E12, 2003;






Diabetes mellitus accelerates aging

Diabetes is associated with a decrease in DNA unwinding rate, increased collagen cross-linking, increased capillary basement membrane thickening, increased oxidative damage.

These basic changes result in increased clinical signs of aging.

Various trials targeting glycaemic control

UKPDSACCORDADVANCE VADT

Most Intensive Less Intensive Least Intensive

Patient Age

Disease Duration

40 45 50 55 60 65 70 75

5 10 15 20

Other Comorbidities

None Few/Mild Multiple/Severe

Hypoglycemia RiskLow HighModerate

8.0%6.0% 7.0%

Established Vascular ComplicationsNone Early Micro Advanced Micro

PsychosocioeconomicConsiderationsHighly Motivated, Adherent,Knowledgeable, Excellent Self-Care Capacities, & Comprehensive Support Systems

Less motivated, Non-adherent, Limited insight,

Poor Self-Care Capacities, & Weak Support Systems

Cardiovascular

Individualizing Glycemic Targets in T2DM

Ismail-Beigi, F., et al. Ann Inter Med. 154:554-559, 201114

JNC 8

Threshold = Goal< 60 Years : 140 / 90Diabetic, CKD : 140/90

ACOMPLISH

ACCORD

Non Fatal Stroke (P=0.03)

119 mmHg

133 mmHg

ELDERS

JNC 8

Threshold = Goal > 60 Years : 150 / 90

Elder SBP

Trial Age Base SBP Achieved

SHEP 1991 >60 170 143Syst Eur 1997 >60 174 161HyVET 2008 >80 173 143

Lipids

There are no large trials of lipid-lowering interventions specifically in older adults with diabetes.Cardiovascular prevention with statins, especially secondary benefit, emerges fairly quickly (within 1–2 years) - statins may be indicated in nearly all older adults with diabetes except those with very limited life expectancy.

In populations without diabetes, the greatest absolute benefit of aspirin therapy (75–162 mg) is for individuals with a 10-year risk of coronary heart disease of 10% or greater .diabetes and aged have increased cardiovascular events and aspirin for secondary prevention should be considered in all.

the benefits of aspirin for primary prevention of CVD events have not been thoroughly elucidated in older adults with diabetes and must be balanced against risk of adverse events such as bleeding.






Polypharmacy

polypharmacy is defined as use of six or more prescription medicationsOlder adults with diabetes are at high risk of polypharmacy, increasing the risk of drug side effects and drug-to-drug interactions.

decreased socialization, sleep and appetite disturbances, higher health care costs and utilization











The prevalence and incidence rates of diabetes mellitus in elderly subjects (> 65 years) may be underestimated when using only fasting plasma glucose.The presence of isolated post-challenge hyperglycaemia (IPH) is common in older subjects and should alert the clinician to screen for cardiovascular disease and institute risk intervention strategies to minimise premature death.

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.

Each functional assessment must include a measure of the three major domains of function: global/physical, cognitive and affective

At initial assessment, all older patients aged less than 85 years with diabetes should have a cardiovascular risk assessment undertaken.

The ten-year risk of developing symptomatic cardiovascular disease should be calculated for all patients who have 2 or more risk factors to assess the need for primary prevention.

For older patients with no comobidities a HBA1C of 7-7.5% should be targeted.

For frail patients where the hypoglycaemia risk is high the target HbA1c range should be 7.6-8.5%.

Metformin should normally be first line therapy for overweight older adults with type 2 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. 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. glargine, determir) rather than NPH-insulin should be considered in older patients

All physicians involved in the care of older patients with type 2 diabetes should assess the risk of hypoglycaemia and adjust therapy to minimise this risk.

Where the risk of hypoglycaemia is moderate (renal impairment, recent hospital admission) to high (previous history, frail patient with multiple comorbiditities, resident of a care home) use an agent with a lower hypoglycaemic potential, e.g. DPP4 inhibitor, lower risk sulphonylurea.

In older patients with a sustained blood pressure (≥140/80 mmHg) – first line therapies can include: use of ACE inhibitors, angiotensin II receptor antagonists, long-acting calcium channel blockers, beta blockers or thiazide diuretics. Use of a perindopril-based regimen in older patients with type 2 diabetes (with or without hypertension) improves both microvascular and macrovascular outcomes.

In subjects with no history of cardiovascular disease, a statin should be offered to patients with an abnormal lipid profile if their 10-year cardiovascular risk is high .

A statin should be offered to patients who have proven cardiovascular disease.

Optimal glucose regulation may help to maintain cognitive function in older people with type diabetes.

To maintain vision in older patients with type 2 diabetes and established retinopathy, optimal blood pressure control (≤140/80 mmHg) and optimal glycaemia (HbA1c 7.0 – 7.5%) should be aimed for.

For painful diabetic neuropathy gabapentin can be used in older patients and is superior to placebo in painful diabetic neuropathy and has fewer side-effects than tricyclic antidepressantsA multidisciplinary Falls Intervention programme should be offered to all patients with a history of a fall or who by virtue of other risk factors have a high risk of falling.






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Diabetes and elderly