Diabetes: a key problem in elderly

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2 Diabetes: a key problem in elderly

3 노인인구의급격한증가 자료 : 통계청. 고령자통계. 2005

4 Prevalence of diagnosed and undiagnosed diabetes and IGT by age and sex, KOREA Park Y, et al. Diabetes Care. 18(4):545-8, 1995

5 2005 년도우리나라당뇨병유병률 30 세이상대상전체대비 : 8.1% 연령별유병율 (%) 성별유병율 (%) 20대 30대 40대 50대 60대 70대 남 여 2005 년도국민건강영양조사자료

6 Diabetes: a key problem in elderly Higher rates of (than those without diabetes) Premature death Functional disability Coexisting illnesses (HTN, CHD, and stroke) Greater risk for several common geriatric syndromes Polypharmacy Depression Cognitive impairment Urinary incontinence Injurious falls ADA. Diabetes Care 31 Suppl 1:S12-54, 2008

7 Predisposing factors to T2DM in the elderly Advanced age Family history of type 2 diabetes Race (African American, Hispanic, native American) Lifestyle Obesity with central fat distribution Physical inactivity Diet high in fat & sugar and low in complex CHO Drug therapy (diuretics, corticosteroids, etc.) Metabolic alterations Impaired insulin release (lean) Insulin resistance (obese)

8 Prevalence of diagnosed & undiagnosed diabetes by age, NHANES, E Selvin et al. Diabetes Care 29: , 2006

9 Symptoms in elderly diabetics Due to physiologic changes associated with aging, may not present with classic symptoms The renal threshold for glucose glycosuria may not be seen Typical symptoms may be masked Initial presentation may be dehydration with altered thirst perception & delayed fluid supplementation. (Dry eyes, dry mouth, confusion, incontinence or complications relating to diabetes)

10 Diagnostic considerations 노화에따른인슐린감수성저하로내당능장애가발생하고당뇨병의유병률증가 65% 75 gm OGTT pp2hr PG 200 mg/dl (WHO Criteria) 26% 9% FPG 126 mg/dl (ADA Criteria) * 당뇨병학회진단소위원회권고안 (2005) 서울서남부지역노인인구의당뇨병유병률 : 20.5% 당뇨병의과거력있는경우 11.9% 새롭게진단된환자 8.6% 공복혈당만으로진단할때상당수의당뇨병이진단되지않음 -2 단계공복혈당장애 ( mg/dl) 의경우경구포도당부하검사가필요 백세현등. 당뇨병 25: , 2001

11 경구당부하검사 당뇨병의진단을위해기본적인검사로권하지않음 선별검사로서필요한경우 공복혈당장애 공복혈당이정상이나당뇨병의고위험군 공복혈당이유용한검사가되기어려운 60 세이상의노인인구 혈당검사가모호하거나임신중인사람 역학연구등 당뇨병진료지침, 대한당뇨병학회, 2007

12 Similarities / Differences Similarities Macrovascular complication: major cause of morbidity and mortality Co-occurrence of other atherosclerotic risk factors Differences Heterogeneous both with respect to diabetes and general health status Prone to complications of treatment Special evaluation and Tx. goal for frail elderly patients

13 Principles of care of older adults with diabetes Clinical and functional heterogeneity Duration of diabetes Diabetic complications Frailty Diabetes-related comorbidity Limited physical or cognitive functioning Life expectancy Must take this heterogeneity into consideration when setting and prioritizing treatment goals ADA. Diabetes Care 31 Suppl 1:S12-54, 2008

14 Therapeutic considerations Age & Life expectancy Multiple pathology : CAD, hyperlipidemia, hypertension Presence of microvascular complications Polypharmacy : thiazide, beta-blocker, etc. Psychosocial problem: depression, anorexia, drugs & poor oral intake Age-related changes in pharmacokinetics - Renal & hepatic function - Drug induced hypoglycemia - Potential for adverse effects

15 Aims in managing diabetes in the elderly To alleviate symptoms of hyperglycemia To achieve a long term control of HbA 1C & postprandial glucose levels To assess & manage the impact of coexisting diseases (e.g. ischemic heart diseases) To avoid hypoglycemia & other adverse drug reactions To screen for & prevent complications To Identify & treat risk factors for atherosclerotic ds. To Improve general health, including functional abilities & nutritional status

16 Guidelines for diabetes care in elderly CHCF/AGS: Guidelines for Improving the Care of the Older Person with Diabetes Mellitus JAGS (supplement) May 2003 American Diabetes Association. Standards of Medical Care in Diabetes Diabetes Care (supplement 1) 2008

17 Guideline: Application What are the patient s goals? What conditions pose the greatest risk for morbidity and mortality? What is the ARR and time to benefit for an intervention? Is the patient likely to benefit given their estimated life expectancy? Quality of life?

18 NNT to prevent one event (in person years/event) Category DM endpoint CVD events All-cause mortality Glucose control (NS) HTN treatment Lipid management *NNT (number needed to treat) UKPDS 33; UKPDS 34; UKPDS 38; Tuomilehto, 1999; Lievre, 2000; Estacio, 2000; microhope, 2000; Estacio, 2000; Sacks, 1996; Elkeles, 1998; Rubins, 1999; Heart Protection Study (CHF/AGS AGS Symposium, May 2003)

19 Time needed to benefit Control of: Microvascular Complications (Median Years) Macrovascular Complications (Median Years) Glycemia 8 Blood pressure Lipids 3 to 6

20 Benefits of glycemic control in microvascular Cx. To properly evaluate the potential benefits of therapeutic interventions on microvascular complications in type 2 diabetes, clinicians must carefully consider the patient's age at onset, overall health status/expected survival, and existing level of glycemic control Vijan S, et al. Ann Intern Med. 127(9):788-95, 1997

21 Glycemic control in elderly diabetics Older adults who are functional, cognitively intact, and have significant life expectancy Should receive diabetes treatment using goals developed for younger adults Older adults who do not meet the above criteria Relaxed using individual criteria Hyperglycemia leading to symptoms or risk of acute hyperglycemic complications should be avoided ADA. Diabetes Care 31 Suppl 1:S12-54, 2008

22 Treatment goals in frail & not frail elderly diabetics Frail elderly diabetics Elderly diabetics Fasting plasma glucose < 180 mg/dl < 140 mg/dl PP2hr PG < 250 mg/dl < 200 mg/dl HbA1C < 8% < 7% Meneilly et al., Diabetes in the Elderly in Endocrinol. of Aging 2001

23 Management of hyperglycemia If healthy & functional, target A1C <7% (IIIB) If frail or ill, target A1C 8% (IIIB) Monitor A1C q 6-12 months (IIIB) Consider self-monitoring in context (IIIB) If hypoglycemic severe or frequent, refer (IIB) Avoid chlorpropamide (IIA) Avoid metformin if scr > mg/dl (IIB) If on metformin, monitor scr or CrCl (IIB) (at least annually, any increase in dose) Brown AF, et al. J Am Geriatr Soc. 51(5 Suppl Guidelines):S265-80, 2003

24 Control of other cardiovascular risk factors Should be treated with consideration of the timeframe of benefit and the individual patient Greater reductions in morbidity and mortality than from tight glycemic control alone Strong evidence from clinical trials of the value of treating hypertension in the elderly Less evidence for lipid-lowering and aspirin therapy ADA. Diabetes Care 31 Suppl 1:S12-54, 2008

25 Management of hypertension Target 140/80 (IA) or 130/80 (IIA) mmhg Rx. hypertension gradually (IIIA) (reduced tolerance) If sysbp & dias BP<100, Rx. in 3 mo (IIIB) If sys BP>160 or dias BP >100, Rx. in 1 mo (IIIB) If on ACEI or ARB, monitor SCr & K (IIIA) (within 1-2 wks of initiation, each dose increase, at least yearly) If on diuretics, monitor electrolytes (IIIA) (within 1-2 wks of initiation, each dose increase, at least Brown AF, et al. J Am Geriatr Soc. 51(5 Suppl Guidelines):S265-80, 2003

26 Management of dyslipidemia Correct dyslipidemia, unless frail or ill (IA) Add pharmaco-rx. if LDL-C >130 mg/dl (IIIB) If statin, monitor ALT at 12 wks & change (IIIB) If fibrate, monitor liver enzymes annually (IIB) Brown AF, et al. J Am Geriatr Soc. 51(5 Suppl Guidelines):S265-80, 2003

27 Management of other CV risk factors Aspirin ( mg/d) if not on other anticoagulants & not contraindicated (IB) Smoking cessation (IIA) Brown AF, et al. J Am Geriatr Soc. 51(5 Suppl Guidelines):S265-80, 2003

28 Psychosocial management Screen for depression (IIA) If depressed, treat or refer in 2 wks (IIIB) Evaluate within 6 wks of initiation (IIIB) Counsel to keep updated med list (IIA) Review med list if depressed, fall, impaired (IIA) Screen for cognitive impairment (IIIA) If impaired, screen for cause (IIIA) Brown AF, et al. J Am Geriatr Soc. 51(5 Suppl Guidelines):S265-80, 2003

29 Screening for diabetic complications Should be individualized Particular attention should be paid to complications that can develop over short periods of time and/or that would significantly impair functional status, such as visual and lower-extremity complications. ADA. Diabetes Care 31 Suppl 1:S12-54, 2008

30 Screening for diabetic complications Dilated-eye exam at diagnosis (IB) and every 1-2 years thereafter (IIB) Screen for microalbumin at Dx. & annually (IIIA) Brown AF, et al. J Am Geriatr Soc. 51(5 Suppl Guidelines):S265-80, 2003

31 DM education Educate and reinforce (IA) Review monitoring technique (IIIB) Evaluate regularly for physical activity (IA) and diet & nutritional status (IA) Educate about new medication (IIIA) and risk factors for foot ulcers & amputation (IB) Brown AF, et al. J Am Geriatr Soc. 51(5 Suppl Guidelines):S265-80, 2003

32 Use of antidiabetic drugs in elderly patients Our knowledge of oral antidiabetic drugs in elderly subjects is limited extrapolation of evidence obtained in young diabetics or patients with renal impairment but not diabetes No midterm morbidity-mortality study Limitations of current therapeutic guidelines

33 Mechanism of action of the oral agents

34 Sulfonylureas Drugs with a long plasma elimination half-life (chlorpropamide, glibenclamide) should be avoided. Favor of short half-life product with moderate hypoglycemic effect and without an active metabolite Should be used with caution because the risk of hypoglycemia increases exponentially with age The most frequent contraindication in the elderly diabetic is advanced-stage renal failure, the nonconsensual creatinine clearance cutoff being between 30 and 50 ml/min.

35 Sulfonylureas Given at a low dose initially then progressively increased (initial doses should be half those used for younger people, and doses should be increased more slowly) Gliclazide and glimepiride are the preferred sulfonylureas, as they are associated with a reduced frequency of hypoglycemic events compared with glyburide.

36 Glinides No specific clinical study in geriatric patients Lower risk for hypoglycemia (short half-life, short onset of actopn) Indicated in mild renal impairment or irregular diet Contraindications are severe renal failure (creatinine clearance < 30 ml/min), liver disease, and association with gemfibrozil

37 Metformin Appealing for older overweight diabetic patients Lactic acidosis: more frequently in old patients with renal failure and tissue hypoxia Contraindicated in patients with Renal failure (creatinine: men > 1.5 mg/dl, women > 1.4 mg/dl) Tissue hypoxia (heart or respiratory failure, obliterating arteriopathy of the lower limbs) Liver failure

38 Metformin Discontinued during inter-current events (dehydration, surgery, injection of iodine contrast agent) Elderly patients have decreased muscle mass, and their serum creatinine may not reflect the true creatinine clearance. Therefore a 24-hour urine sample should be ordered for patients over 70. Treatment should not be initiated in patients >80 years unless measurement of creatinine clearance demonstrates that renal function is not reduced.

39 α-glucosidase inhibitors Reduces post-prandial hyperglycemia with lesser effect on fasting glucose levels Pharmacokinetic properties are not affected by aging Contraindications: obstructive-like syndromes, inflammatory bowel diseases, intestinal hernia, and severe renal failure (creatinine clearance < 25 ml/min), conditions which are frequent in geriatric patients

40 α-glucosidase inhibitors The advantage in the elderly is its safety profile Not provoke hypoglycemia Limited by the frequent adverse GI effects (flatulence, or even diarrhea in 30-80%) starting with a smaller dose and gradually increasing the dosage if required can minimize this More serious GI risk with Hx. of digestive tract ds., autonomic neuropathy, or anticholinergic drug concomitantly

41 Thiazolidinediones (TZD) Changes in the pharmokinetic properties not been reported in patients with CRF (mild to severe) irrespective of age Efficacy is similar in old and young type 2 diabetics Lower risk of hypoglycemia Problem in fluid retention & weight gain Main contraindications: ESRD (creatinine clearance < 4 ml/min), liver disease (particularly liver failure), and heart failure (all stages) Non-significant trend towards more adverse events

42 Insulin & Insulin Analogues The risk of severe hypoglycemia associated with insulin increases with age No specific regimen or form of insulin has been identified as particularly advantageous to the elderly. In elderly people, the use of premixed insulins and prefilled insulin pens as an alternative to mixing insulins should be encouraged to reduce dosage errors and potentially improve glycemic control.

43 Insulin & Insulin Analogues Problems Visual impairment Difficulty in drawing & injecting the exact dose of insulin Impaired manual dexterity Decreased sensation in the hands Limited access to injection sites Difficulties in monitoring blood glucose A complete geriatric assessment should be performed first to assure that patients can comply with their regimens and to identify potential complicating factors.

44 Attitudes delay use of effective diabetes therapy More than half are worried about starting on insulin Half believe that starting on insulin would mean they had failed to manage their disease Only one fifth believe insulin would help them manage their diabetes better More than one third of physicians postpone insulin until absolutely essential! Two-thirds use insulin as a threat with their patients

45 Considerations in starting insulin therapy Patient & doctor s own will Vision Manual dexterity Sensation in hands Access to injection sites Cost Ability to perform self-monitoring of blood glucose (SMBG) Cognitive function Family support

46 Hypoglycemia: risk of diabetes treatment Glucose counter-regulation involving glucagon, epinephrine and growth hormone responses to hypoglycemia are diminished. This may contribute to the reduction in autonomic warning symptoms. Symptoms might not appear until there is severe hypoglycemia at levels <50 mg/dl due to these counterregulation changes.

47 Factors that predispose to hypoglycemia in elderly Poor or erratic nutritional intake Changes in mental status that impair the perception or response to hypoglycemia Polypharmacy and noncompliance with medications Dependence or isolation that limits receipt of early treatment for hypoglycemia Impaired renal or hepatic metabolism Presence of comorbid conditions that can mask or lead to misdiagnosis of hypoglycemic symptoms (dementia, delirium, depression,

48 Cognitive impairments The mechanisms: unclear Limitations in their activities of daily living Undiagnosed depression Difficult social issues Coexisting health problems, such as dementia or psychiatric illnesses Lower levels of cognitive functioning Greater cognitive decline in the elderly The risks of hypoglycemia are higher: impaired awareness of the autonomic warning symptoms

49 SUMMARY Understanding of difference in elderly diabetics Stepwise approach & Conservative management Proper education Importance of Individualized goal-setting