Diabetes Mellitus in Older Adults - Joslin Diabetes · PDF fileMicrosoft PowerPoint - Slides 16 Diabetes in Older Adults Munshi.ppt [Compatibility Mode]

Joslin Diabetes CenterAdvances in Diabetes and Thyroid Disease 2013Diabetes Mellitus in Older Adults

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Diabetes Mellitusin Older Adults

Medha Munshi, M.D.Joslin Diabetes Center

Beth Israel Deaconess Medical CenterHarvard Medical School

Presenter Disclosure Information

Medha Munshi

Research grant from Sanofi

Goals and Objectives

• Older patients vs younger adults

• Goals of treatment

• Management strategy

1



Diagnosed and Undiagnosed Diabetes

0

5

10

15

20

25

30

20-44 45-64 65 and over

2010

2005-2008 NHANES: national diabetes fact sheet 2011; CDC

Per

cen

tag

e

Case History

• 85 years old patient with diabetes

Questions:

- what is different in presentation?

- when does this patient need treatment?

- what is the best treatment for this patient?

2



Heterogeneity in EnvironmentIn Older Adult With Diabetes

Communityliving

Alone

spouse

OtherFamily member

Older adultWith diabetes

FunctionallydisabledHighly

functional

Assisted carefacilities

Nursing home

Diabetes

Co-morbidities in Aging and Diabetes

Macro/Micro vascular dzCognitive dysfunction

DepressionPhysical disability

Polypharmacy

Aging

Cognitive DysfunctionExecutive Dysfunction

• Frontal lobe mediated higher functions– Insight in to the

problem

– Planning and judgment

– Problem solving

– Starting, changing or stopping behavior

3



Case History – Mr. D

• 82 yo male

• Engineer—computer savvy

• DM duration 17 yrs

• Glargine BID and lispro before meals

• A1C 6.5%

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

InstructionForm:

ResponseForm:

Modified Clock-In-a-Box(CIB)

Cognitive Dysfunction in Older Adults With and Without DM

34

18.5

0

5

10

15

20

25

30

35

40

Older Adults without DM Older Adults with DM

>70 yrs

Munshi et al. Diabetes Care. 2006;29(8):1794-1799.Health and retirement study (CDC).

4



Cognitive Dysfunction Associated with Poor Diabetes Control

6.87

7.27.47.67.8

88.28.48.68.8

Cognitive Dysfunction Cognitively Intact

A1

C

P<0.002

Munshi et al. Diabetes Care. 2006;29(8):1794-1799

Depression in Older Adults With and Without DM

11

32

18

35

0

5

10

15

20

25

30

35

40

Older Adults without DM Older Adults with DM

Men

Women

Munshi et al. Diabetes Care. 2006;29(8):1794-1799.Health and retirement study (CDC).

Depressive Symptoms Associated with Increased Risk of Functional Disability

3

3.5

4

4.5

5

5.5

6

Without Depression With Depression

P<0.03

*

Munshi et al. Diabetes Care. 2006;29(8):1794-1799.

5



For Women Living Alone, Glycemic Control Worsens as Number of Medications Increases

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

A1

C

Hayes M et al; Diabetes 2006; A212

Functional Impairmentin the Elderly With Diabetes

Hearing Impairment 48 %

Vision Impairment 53 %

History of Recent Falls 33 %

Fear of Falls 43 %

Independent in ADL 95 %

Independent in IADL 38 %

Munshi et al. Diabetes Care. 2006;29(8):1794-1799.

CVD PVD

Retinopathy Nephropathy

Morbidityand Functional

Disability

Morbidity Mortality

Depression

PhysicalDisability

Cognitive Dysfunction

Polypharmacy

FallsNeuropathyUrinary

Incontinence

DiabetesMellitus

Hypoglycemia

Compliance

Quality of life

Complex Interactions in Older Adults with Diabetes

CAD

6



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 <130/80 mm Hg– LDL cholesterol <100 mg/dl– Cessation of cigarette smoking– Low dose aspirin therapy– Yearly screening for microalbuminuria (ACE

inhibitors), retinopathy, foot examination

Goal- Setting

Glycemic Goal

HypoglycemiaSocial support and

Living situation

Life expectancyFinancial issues

Physical abilities

A1C: Marker of Glycemic Control

• Increases with increasing age

• Affected by red cell life span

• Role of renal dysfunction and anemia of chronic diseases not known

• Reflects average glucose – miss BG fluctuations

7



A1C - 8.2%

Insulin only

A1C - 8.3%

Insulin and oral

Hypoglycemia in older adults

Hypoglycemia &Fear of hypoglycemia

Noncompliance

Hypoglycemiaunawareness

Cognitive dysfunctioninterfering with

identification/treatmentof hypoglycemia

Co-morbiditiesmimicking

hypoglycemicsymptoms

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

8



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 unlessnot tolerated

Complex/Intermediate- Multiple co-existing

illnesses- Mild-moderate cognitive

impairment- 2+ instrumental ADL

Intermediate life expectancyHigh treatment burdenHypo vulnerabilityFall 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 expectancyBenefits uncertain

<8.5% <150/90 Consider risks and beneftis

A Framework for Treatment Goals

Kirkman MS et al; Diabetes Care. 2012 Dec;35(12):2650-64

Current A1c

<7%

Multiple Comorbidities

or medications

that may cause

hypoglycemia

LiberalizeGoal

Few Comorbidities

andMedications 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 Algorithmin Elderly

9



Class A1C Reduction

Fasting vs PPG

Hypo-glycemia

Weight Gain

Dosing (times/day)

Other Safety Issues

Metformin 1.5 Fasting No Neutral/Loss

2 GI, lactic acidosis

Insulin (long-acting)

1.5–2.5 Fasting Yes Gain 1, Injected

Insulin (rapid-acting)

1.5–2.5 PPG Yes Gain 1–4, Injected

Sulfonylureas 1.5 Fasting Yes Gain 1 Allergies,secondary failure

Thiazolidinediones

0.5–1.4 Fasting No Gain 1 Edema, CHF, bone fractures

GLP-1 agonist (short-acting)

0.5–1.0 PPG No Loss 2, Injected GI, ARF, ?pancreatitis

Repaglinide 1.0–1.5 Both Yes Gain 3

Nateglinide 0.5–0.8 PPG Rare Gain 3

Adapted from Nathan DM et al. Diabetes Care. 2007;30:753-759. | Nathan DM et al. Diabetes Care.2006;29:1963-1972. | Nathan DM et al. Diabetes Care. 2009;32:193-203. | ADA. Diabetes Care.2008;31:S12-S54. I WelChol PI. 1/2008. Cycloset PI. 5/2009. | Buse JB et al. Lancet. 2009;374:39-47.

ARF = acute renal failure; GI = gastrointestinal; GLP = glucagon-like peptide

15 Classes of Antidiabetes Medications

15 Classes of Antidiabetes MedicationsClass A1C

ReductionFasting vs PPG

Hypo-glycemia

Weight Gain

Dosing (times/day)

Other Safety Issues

α-Glucosidase inhibitor

0.5–0.8 PPG No Neutral 3 GI

Amylin mimetics 0.5–1.0 PPG No Loss 3, Injected GI

DPP-4 inhibitors 0.6–0.8 Both No Neutral 1 ?pancreatitis

Bile-acid sequestrant

0.5 Fasting No Neutral 1–2 GI

Bromocriptine 0.7 PPG No Neutral 1 GI

GLP-1 agonist (long-acting)

1.0–1.5 Both No Loss ≤1, Injected GI, ?pancreatitis, ?MTC, ?ARF

(SGLT-2 inhibitors)

<1 Both No Loss 1 ??

Adapted from Nathan DM et al. Diabetes Care. 2007;30:753-759. | Nathan DM et al. Diabetes Care.2006;29:1963-1972. | Nathan DM et al. Diabetes Care. 2009;32:193-203. | ADA. Diabetes Care.2008;31:S12-S54. I WelChol PI. 1/2008. Cycloset PI. 5/2009. | Buse JB et al. Lancet. 2009;374:39-47.

ARF = acute renal failure; DPP-4 = dipeptidylpeptidase-4; GI = gastrointestinal; GLP = glucagon-likepeptide; MTC = medullary thyroid cancer; SGLT-2 = sodium-glucose transporter-2

Insulin Action

10



Higher contribution of post-pradial glucose in hyperglycemia in

older vs younger adults

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

TZDs

Diagnosis

SulfonylureaStart low and

Increase dose astolerated

GLP- 1 agonist

Add second and/or third agent as needed

Normal Abnormal

Renal function

MetforminStart @ 500 mg/d

Increase by 500 mgUp to 2000 mg/d

Cognitive function

No CHFNormal LFT

Algorithmfor themetabolic managementof older adults with diabetes

DPP 4 inhibitors

-Long acting and NPH or mix insulin in am

UncontrolledWith oral Meds

Long acting insulinPm dosing

OrNPH at bedtime

Post prandial hyperglycemia

High FBS

Long acting insulinAm dosing

Algorithmfor themetabolic managementof older adults with diabetes

-Low AM, high PM-memory loss

11



Use of serum c-peptide to simplify 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

Simplification of RegimenImproves Glucose Excursions

A1c 7.5% Aspart Mix 70/30 30 units BIDTime < 70mg/dL: 590 min Metformin 1000mg QAM, 500mg QPM

A1c 7.2% Glargine 40 units QAMTime < 70mg/dL: 0 min Metformin 1000mg BID

Munshi et al; abstract presentation at ADA June 2013

Summary

• Older patients vs younger adults– Clinical presentation is variable

• Goals of treatment– Consider co-existing conditions– Risks vs Benefit of treatment– A1c vs hypoglycemia - parameters for glycemic

goals

• Management strategy– Matching patients’ coping skills to the complexity

of the treatment– KISS

12

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Diabetes Mellitus in Older Adults - Joslin Diabetes · PDF fileMicrosoft PowerPoint - Slides 16 Diabetes in Older Adults Munshi.ppt [Compatibility Mode]