Diabetes Care for Older Adults: Evidence–based Strategies for Glycemic Treatment in Older Adults Medha Munshi, MD

Friday, February 9, 2018 3:30p.m. – 4:15 p.m.

Older adults with diabetes are a growing population with unique needs. Many older adults with diabetes have coexisting chronic medical conditions, such as cognitive dysfunction, depression, functional limitations, vision impairment, and hearing impairment. These conditions further put them at risk of falls, fractures, and functional dependency. Screening and early detection of these conditions is indicated to understand patient's inability to perform self-care. Overall treatment strategies and selection of medications in older adults with diabetes should be guided by their self-care abilities. In general, older adults are at increased risk of hypoglycemia and its poor consequences. Medications with low risk of hypoglycemia should be preferred in this population. Glycemic goals should be individualized carefully based on disease characteristics, patient preference, and self-care abilities. Recent data has shown that, over treatment of diabetes in older adults is common and should be avoided. De-intensification of complex regimens can be successfully achieved in older adults, without compromising their glycemic goals. Simplification can improve benefits of diabetes management along with overall quality of life.

References

1. Kirkman MS, Briscoe VJ, Clark N, Florez H, Haas LB, Halter JB, Huang ES, Korytkowski MT, MunshiMN, Odegard PS, Pratley RE, Swift CS: Diabetes in Older Adults; 2012 Dec; 35(12); 2650-64; PMID 23100048 2. Older Adults: Standards of Medical Care in Diabetes-2018. Diabetes Care January; 41;(supplement 1); S119-125. 3. Pharmacological approaches to Glycemic Treatment: Standards of Medical Care in Diabetes-2018. Diabetes Care January 2018; 41;(supplement 1); S73-85. 4. Munshi, MN, Slyne C, Segal AR, Saul N, Lyons C, Weinger, K. Simplification of insulin regimen inolder adults improves risk of hypoglycemia without compromising glycemic control. In press, JAMA Intern Med 2016 Jul 1;176(7):1023-5. PMID:27273335 5. Munshi MN, Florez H, Huang E.S., Kalyani R.R., Mupanomunda M, Pandya N, Swift C.S., TaveiraT.H., Hass L.B: Management of Diabetes in Long-term Care and Skilled Nursing Facilities: A Position Statement of the American Diabetes Association. Diabetes Care 2016; Feb: 39(2):308-318. PMID: 26752195 6. Lipska KJ, Ross JS, Wang Y, et al. National Trends in US Hospital Admissions for Hyperglycemiaand Hypoglycemia Among Medicare Beneficiaries, 1999 to 2011. JAMA Intern Med 2014

Diabetes in Older Adults:Evidence-based Strategies for Glycemic

Treatment

Medha Munshi, M.D.

Associate Professor, Harvard Medical School

Director, Joslin Geriatric Diabetes Program

Geriatrician, Beth Israel Deaconess Medical Center

Boston, Massachusetts

Presenter Disclosure Information

Presenter: Medha Munshi

Consultant /Advisory Panel: Sanofi

Objectives

Glycemic Treatment in older adults

• Unique characteristics of population

• Complexity associated with glycemic goal-setting

• Effective strategies for treatment

Who is an older adult?

Ph

ysio

log

ical re

serv

e

Po

or

ou

tco

mes

AGE

Physiologic limit beyond whichHomeostasis can not be restore

stressor

HomeostenosisProgressive constriction of homeostatic reserve

Allows us to maintain homeostasis in presence ofEnvironmental, physiological, or emotional stress

Where do you treat an 80 years old patient

Independent

living

Assisted Care Nursing home

• Complex regimen

can be dangerous

if patient unable

to follow them

• Acute illness

cause ↓ cognitive

or physical status

• Need frequent

education and

reeducation

• May/may not have

control over meal

content

• Assistance with

medications but not BS

monitoring or insulin

• High risk of failure after

acute illness

• Little control over

time/content of diet

• Higher risk of side

effects with oral

medications

• Higher risk of acute

illness, anorexia,

dementia/delirium

• Self-care performed

by NH staff

Diabetes Management Challenges

Diabetes

Co-morbidities in Aging and

Diabetes

Macro/Micro vascular dz

Cognitive dysfunction

Depression

Physical disability

Polypharmacy

Aging

Memory loss: Mr. JB Cognitive DysfunctionExecutive Dysfunction

• Frontal lobe–mediated:

higher function

– Insight in to the problem

– Planning and judgment

– Problem-solving

– Starting, changing, or

stopping behavior

Case History – Mr. D

• 82 yo male

• Engineer—computer savvy

• DM duration 17 yrs

• Glargine BID and lispro before meals

• A1C 6.5%

Case History – Mr. D

Case History – Mr. DError in Problem Solving

Please read and do the following carefully:

➢ In the blue box on the next page:

➢ Draw a picture of a clock

➢ Put in all the numbers

➢ Set the time to ten after eleven

Hand this sheet back and go to the next page

Instruction

Form:

Response

Form:

Modified Clock-in-a-Box (CIB)

Mrs. MBAge: 68 yrs, DM: 45 yrs, basal-bolus regimenDifficulty With Problem- Solving Mrs. MB

Mr. JW Mr. JWCaregiver Support

Cognitive Dysfunction in Older Adults With and Without DM

Munshi M et al. Diabetes Care. 2006;29:1794-1799

Health and retirement study (CDC).

34

18.5

0

5

10

15

20

25

30

35

40

Older Adults Without DM Older Adults With DM

>70 yrs

Cognitive Dysfunction Associated With Poor Diabetes Control

Munshi M et al. Diabetes Care. 2006;29:1794-1799.

Health and retirement study (CDC).

6.8

7

7.2

7.4

7.6

7.8

8

8.2

8.4

8.6

8.8

Cognitive Dysfunction Cognitively Intact

A1C

P < .002

Depression in Older Adults With and Without DM

Munshi M et al. Diabetes Care. 2006;29:1794-1799.

Health and retirement study (CDC).

11

32

18

35

0

5

10

15

20

25

30

35

40

Older Adults without DM Older Adults with DM

Men

Women

*

Depressive Symptoms Associated With ↑ Risk of Functional Disability

Munshi M et al. Diabetes Care. 2006;29:1794-1799.

Health and retirement study (CDC).

3

3.5

4

4.5

5

5.5

6

Without Depression With Depression

P<0.03

PolypharmacyMrs. M: Age: 92 years, legally blind, 14 meds/day

Women Living AloneGlycemic control worsens as medications taken increase

Hayes M et al. Diabetes. 2006;908.

5.00

5.50

6.00

6.50

7.00

7.50

8.00

8.50

9.00

9.50

0 5 10 15 20

Medication Count

A1C

Management of Diabetes in Older Adults

• Screening for barriers

– Clinical / functional / psychosocial

• Management of hyperglycemia

– Medications

– Diet

– Exercise / physical activity

• Management of risk factors

– BP control

– LDL cholesterol

– Cessation of cigarette smoking

– Low-dose aspirin therapy

– Yearly screening for microalbuminuria (ACE inhibitors),

retinopathy, foot examination

Glycemic Goal

Optimize benefits – Minimize harm

Hyperglycemia

(A1C)Hypoglycemia

Conditions Possible mechanisms Change in A1C

Age Unknown

Race – AA / Hispanic unknown

Iron deficiency anemia ↓ RBC turnover

Recent infection Insulin resistance

Transfusion ↑ RBC turnover

Hemodialysis ↓ RBC life span

Erythropoietin therapy ↑ young RBC

Metabolic acidosis / uremia Carbamylation of hemoglobin

Anemia of chronic diseases Unknown

Conditions commonly seen in elderly

that may affect A1C levels

Is A1C dependable marker of glycemic control

in older adults?

A1C - 8.2%

Insulin only

A1C - 8.3%

Insulin and oral

Hypoglycemia in older adults

Hypoglycemia &

Fear of hypoglycemia

Noncompliance

Hypoglycemia

unawareness

Cognitive dysfunction

interfering with

identification/treatment

of hypoglycemia

Co-morbidities

mimicking

hypoglycemic

symptoms

Insulin therapy

in older adults

Falls, hospital visitsExacerbation of

chronic conditions

Even mild hypoglycemia may result in poor outcome

Frequent Hypoglycemic Episodes

Detected by CGM

age>70 yrs; A1C>8%; n=40

Patients with hypoglycemia n = 26 (65 %)

Patients with A1C 8-9 % 14 (54 %)

Patients with A1C > 9 % 12 (46 %)

Severity of hypoglycemic episodes

60-69 mg/dl 100 %

50-59 mg/dl 73 %

< 50 mg/dl 46 %

Munshi et al; Arch Intern Med. 2011;171(4):362-364

National Trends in US Hospital Admissions

for Hyper/HypoglycemiaMedicare Beneficiaries 1999-2011

Lipska et al; JAMA intern Med 2014; 174(7): 1116-24

Absolute risk of hypoglycemia; 100,000 ED admissions /year

Diabetes Care. 2012 Dec;35(12):2650-64

J Am Geriatr Soc. 2012 Dec;60(12):2342-56

Patient characteristics

/health status

Rational A1C BP Lipids

Healthy

- few co-existing illnesses

- intact cognitive status

- intact functional status

Longer life

expectancy

<7.5% <140/80 Statins

unless

not

tolerated

Complex/Intermediate

- Multiple co-existing

illnesses

- Mild-moderate cognitive

impairment

- 2+ IADL dependency

Intermediate life

expectancy

High treatment

burden

Hypo vulnerability

Fall risk

<8% <140/80 Statins

unless

not

tolerated

Very Complex/Poor Health

- LTC care residents

- end-stage chronic illnesses

- Moderate-severe cognitive

impairment

- 2+ ADL dependencies

Limited life

expectancy

Benefits uncertain

<8.5% <150/90 Consider

risks and

benefits

A Framework for GoalsConsensus report (ADA)

Kirkman MS et al; Diabetes Care. 2012 Dec;35(12):2650-64 Lipska K et al; JAMA int med 2015;175;3;356-62

DM control across health status A1C<7% across health status

Potential Overtreatment in Older adultsNHANES: 2001-2010

Is it intuitive to liberate goals in older adults?

Current A1c

<7%

Multiple

Comorbidities

or

medications

that may

cause

hypoglycemia

Liberalize

Goal/

change strategy

Few

Comorbidities

and

Medications

unlikely to

cause

hypoglycemia

At goal with caution

(Continually assess

for hypoglycemia)

7 – 8%

Medications

likely to

cause

hypoglycemia

Carefully assess

for hypoglycemia

or glucose

excursions

At Goal

Present Not Present

Medications

unlikely to

cause

hypoglycemia

> 8%

-Multiple Co-morbidities

-Limited Life Expectancy

-Difficulty coping

Aim for

Goal < 8%

Present Not Present

Goal-setting Algorithm

in Elderly Use of serum c-peptide to simplify

insulin regimen in older adults

• Normal/high serum C-peptide: 65/100

• Age: 79±14 yrs, DM duration: 21±13 yrs

• Number of medications: 11 (range 4-18)

• Simplification completed in 35 patients

• In 19 patients, patients completely off insulin

• In 16 patients number of insulin injections were decreased significantly

• Number of hypoglycemic episodes decreased

• A1c improved from 8% to 7.4% (p<0.002)

Munshi et al; American Journal of Medicine 2009;122;395-97

Higher contribution of post-pradial

glucose in older adults

0

10

20

30

40

50

60

70

<7% 7-8% 8-9% >9%

<65 years

>65 years

PP

HG

co

ntr

ibu

tio

n (

%)

Hemoglobin A1C

Munshi et al, J Am Geriatr Soc. 2013;61:535–541

Case of Mr. GB

22 u of basal insulin with dinner and sliding scare before each meal

Simplification of

Regimen to

Once a day

Glargine

±

Non-insulin

agents

E

v

a

l

u

a

t

i

o

n

- Age >70 yrs

- ≥ 1 insulin

injection/day

- High stimulated

c-peptide

- ≥ 1 episode of

glucose <70

E

v

a

l

u

a

t

i

o

n

Active

Intervention

( 5 months)

Independent

Period

(3 months)

E

v

a

l

u

a

t

i

o

n

No Active

Contact

SIMPLE study

de-intensification

Munshi et al, JAMA Intern Med 2016 July 1:176(7):1023-5

Primary outcome: Duration of hypoglycemia by CGM

Secondary outcome: A1C

Algorithm for Insulin Regimen Simplificationfrom basal-bolus to one injection/day

Change or add long-acting insulin

Change timing from

Bedtime to morning

If on Mixed insulin: Use 70% of the

total dose as basal in the morning

Titrate dose of basal insulin based on FBS weekly 90-150 mg/dl

is as reasonable goal in most pts May change goal based on

overall health

If 50% of the FBS > goal,

↑ dose by 2 u

Change meal-time insulin

If meal-time insulin <10

u/dose: d/c and add

non-insulin agents

If meal-time insulin >10 u/dose:

↓ 50% and add non-insulin agent

Continue to titrate dose of meal-

time insulin down as non-insulin

dose is increased

Baseline eGFR

Follow ADA guideline on adding

Next agents

General tips:

-While adjusting meal-time insulin

May use simplified sliding scale, e.g.

Premeal glucose>250, give 2 u of short-acting insulin

Premeal glucose>350, give 4 u of short-acting insulin

-Stop sliding scale when not needed daily

-Do not use short-acting insulin at bedtime

If >2 fingerstick readings/wk

are <80 mg/dl, ↓ dose by 2 u

Munshi et al, JAMA Intern Med 2016 July 1:176(7):1023-5

S=

Metformin

+Metformin

+

Metformin

+

Metformin

+

Metformin

+

Metformin

+

Metformin

+

Mono-Therapy

DualTherapy

Efficacy

Hypo risk

Weight

Side effects

cost

Sulfonylurea

High

Moderate

Gain

Hypo

Low

TZD

High

Low

Gain

Edema, CHF

Low

DPP4-i

Intermediate

Low

Neutral

rate

High

SGLT2-i

Intermediate

Low

Loss

GU,dehydration

High

Insulin (basal)

Highest

High

Gain

Hypo

High/variable

GLP1 RA

High

Low

Loss

GI

High

Efficacy

Hypo risk

Weight

Side effects

cost

sulfonylurea

+

TZD

DPP4i

SGLT2-I

GLP1-RA

Insulin

TZD

+

sulfonylurea

DPP4i

SGLT2-I

GLP1-RA

Insulin

DPP4-i

+

sulfonylurea

TZD

SGLT2-I

GLP1-RA

Insulin

SGLT2-i

+

sulfonylurea

TZD

DPP4i

GLP1-RA

Insulin

Insulin (basal)

+

sulfonylurea

TZD

DPP4i

SGLT2-I

GLP1RA

GLP1-RA

+

sulfonylurea

TZD

DPP4i

SGLT2-I

Insulin

TripleTherapy

Metformin+

Metformin+

Metformin+

Metformin+

Metformin+

Metformin+

adapted from Diabetes Care 2015;38:140–149

Combination with

injectable

Metformin

+

Basal insulin or meal-time insulin or GLP1-RA

Simplification of insulin regimenimproved hypoglycemia without worsening glycemic control

A1C %Duration of hypoglycemia<70 / 5-day CGM

Munshi et al, JAMA Intern Med 2016 July 1:176(7):1023-5

Scre

enin

g5-

Month

s

A1c 7.4% mixed insulin 70/30 70 units QAM, 45 units QPM

Time<70: 130 mins metformin 500mg BID

A1c 7.0% glargine 66 units QAM, Metformin 1000mg BID,

Time<70: 75 mins glipizide 10mg BID

A1c 7.0% glargine 66 units QAM, Metformin 1000mg BID,

Time <70: 0 mins glipizide 10mg BID

8-

Month

s

5month

8month

Scre

enin

g5 M

onth

8 M

onth

A1c 9.9% detemir 30 u q am and 50 u q hs

Time < 70 mg/dL: 240 min rapid-acting sliding scale preprandial & HS

A1c 10.2% glargine 98 units QAM , Glipizide 10mg BID

Time < 70 : 40 min liraglutide 1.8mg QAM

A1c 8.7% glargine 50 units QAM , 56 units QPM, Glipizide 10mg BID

time<70: 375 mins liraglutide 1.8mg QAM, rapid-actign sliding scale

Table 3 A: Change in Hypoglycemia duration and A1C in groups with different A1C at baseline

Baseline A1C ≤ 7%

N=17

7.1-8 %

N=27

8.1-9 %

N=14

>9%

N=7

Hypo Duration (mins/5 days)

<70 mg/dL

<60 mg/dL

< 50 mg/dL

292±306

146 + 225

76 + 184

292±244

157 + 183

91 + 139

280±260

160 + 174

74 + 115

246±222

162 + 168

56 + 70

Change in A1C

Baseline5 months

Baseline8 months

0.37±0.65

P =0.03

0.48±0.54

P = .04

-0.06±0.68

P= 0.8

0.10±0.59

P= 0.3

-0.52±0.54

P= 0.004

0.17±0.75

P= 0.3

-1.72±2.0

P=0.03

-1.03±1.4

P= 0.2

Table 3b: Duration of hypoglycemia by A1C levels at 5 months and 8 months

5-month A1C ≤ 7%

N=18

7.1-8 %

N=28

8.1-9 %

N=11

>9 %

N=3

Hypo duration (mins/5 days)

<70 mg/dL

<60 mg/dL

< 50 mg/dL

103 ± 120

59 + 85

23 + 55

97 ± 223

57 + 149

23 + 90

151 ± 179

68 + 93

31 + 57

145 ± 153

65 + 96

22 + 38

8-month A1C ≤ 7%

N=11

7.1-8 %

N=25

8.1-9 %

N=15

>9 %

N=4

Hypo duration (mins/5 days)

<70 mg/dL

<60 mg/dL

< 50 mg/dL

34 + 63

21 + 43

14 + 31

167 + 216

87 + 131

43 + 65

46 + 99

27 + 72

10 + 35

104 + 75

86 + 61

48 + 47

Munshi MN et al; J diab and its Compl, July, 2017, Vol 31; 7; 1197-99cc

Summary

Older vs Younger• Unique characteristics of the population

– Older adults are a heterogeneous population

– Aging is associated with Homeostenosis and presence

of comorbidities

• Complexity of the goal-setting

- Avoid dependence on A1C as the sole parameter

- Risk fo hypoglycemia should be carefully assessed

• Effective strategies for treatment

– Avoid overtreatment

– De-intensify and match patient’s coping abilities with

treatment complexity

Aging Successfully Geriatrician’s Serenity Prayer

Wisdom to know when not to mess with it!