Diabetes Care for Older Adults: Evidence based Strategies for Glycemic Treatment in Older Adults References

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1 Dibetes Cre for Older Adults: Evidence bsed Strtegies for Glycemic Tretment in Older Adults Medh Munshi, MD Fridy, Februry 9, :30p.m. 4:15 p.m. Older dults with dibetes re growing popultion with unique needs. Mny older dults with dibetes hve coexisting chronic medicl conditions, such s cognitive dysfunction, depression, functionl limittions, vision impirment, nd hering impirment. These conditions further put them t risk of flls, frctures, nd functionl dependency. Screening nd erly detection of these conditions is indicted to understnd ptient's inbility to perform self-cre. Overll tretment strtegies nd selection of medictions in older dults with dibetes should be guided by their self-cre bilities. In generl, older dults re t incresed risk of hypoglycemi nd its poor consequences. Medictions with low risk of hypoglycemi should be preferred in this popultion. Glycemic gols should be individulized crefully bsed on disese chrcteristics, ptient preference, nd self-cre bilities. Recent dt hs shown tht, over tretment of dibetes in older dults is common nd should be voided. De-intensifiction of complex regimens cn be successfully chieved in older dults, without compromising their glycemic gols. Simplifiction cn improve benefits of dibetes mngement long with overll qulity of life. References 1. Kirkmn MS, Briscoe VJ, Clrk N, Florez H, Hs LB, Hlter JB, Hung ES, Korytkowski MT, Munshi MN, Odegrd PS, Prtley RE, Swift CS: Dibetes in Older Adults; 2012 Dec; 35(12); ; PMID Older Adults: Stndrds of Medicl Cre in Dibetes Dibetes Cre Jnury; 41; (supplement 1); S Phrmcologicl pproches to Glycemic Tretment: Stndrds of Medicl Cre in Dibetes Dibetes Cre Jnury 2018; 41;(supplement 1); S Munshi, MN, Slyne C, Segl AR, Sul N, Lyons C, Weinger, K. Simplifiction of insulin regimen in older dults improves risk of hypoglycemi without compromising glycemic control. In press, JAMA Intern Med 2016 Jul 1;176(7): PMID: Munshi MN, Florez H, Hung E.S., Klyni R.R., Mupnomund M, Pndy N, Swift C.S., Tveir T.H., Hss L.B: Mngement of Dibetes in Long-term Cre nd Skilled Nursing Fcilities: A Position Sttement of the Americn Dibetes Assocition. Dibetes Cre 2016; Feb: 39(2): PMID: Lipsk KJ, Ross JS, Wng Y, et l. Ntionl Trends in US Hospitl Admissions for Hyperglycemi nd Hypoglycemi Among Medicre Beneficiries, 1999 to JAMA Intern Med 2014

2 Dibetes in Older Adults: Evidence-bsed Strtegies for Glycemic Tretment Presenter Disclosure Informtion Presenter: Medh Munshi Consultnt /Advisory Pnel: Snofi Medh Munshi, M.D. Associte Professor, Hrvrd Medicl School Director, Joslin Geritric Dibetes Progrm Geritricin, Beth Isrel Deconess Medicl Center Boston, Msschusetts Objectives Glycemic Tretment in older dults Who is n older dult? Unique chrcteristics of popultion Complexity ssocited with glycemic gol-setting Effective strtegies for tretment Physiologicl reserve Homeostenosis Progressive constriction of homeosttic reserve Allows us to mintin homeostsis in presence of Environmentl, physiologicl, or emotionl stress Physiologic limit beyond which Homeostsis cn not be restore Poor outcomes Where do you tret n 80 yers old ptient stressor AGE

3 Dibetes Mngement Chllenges Co-morbidities in Aging nd Dibetes Independent living Assisted Cre Nursing home Complex regimen cn be dngerous if ptient unble to follow them Acute illness cuse cognitive or physicl sttus Need frequent eduction nd reeduction My/my not hve control over mel content Assistnce with medictions but not BS monitoring or insulin risk of filure fter cute illness Little control over time/content of diet er risk of side effects with orl medictions er risk of cute illness, norexi, dementi/delirium Self-cre performed by NH stff Aging Mcro/Micro vsculr dz Cognitive dysfunction Depression Physicl disbility Polyphrmcy Dibetes Memory loss: Mr. JB Cognitive Dysfunction Executive Dysfunction Frontl lobe medited: higher function Insight in to the problem Plnning nd judgment Problem-solving Strting, chnging, or stopping behvior Cse History Mr. D Error Cse in History Problem Solving Mr. D Cse History Mr. D 82 yo mle Engineer computer svvy DM durtion 17 yrs Glrgine BID nd lispro before mels A1C 6.5%

4 Modified Clock-in--Box (CIB) Instruction Form: Plese red nd do the following crefully: In the blue box on the next pge: Drw picture of clock Put in ll the numbers Set the time to ten fter eleven Hnd this sheet bck nd go to the next pge Response Form: Difficulty With Mrs. Problem- MB Solving Age: 68 yrs, DM: 45 yrs, bsl-bolus regimen Mrs. MB Mr. JW Cregiver Mr. JW Support

5 A1C A1C Cognitive Dysfunction in Older Adults With nd Without DM Cognitive Dysfunction Associted With Poor Dibetes Control Older Adults Without DM 34 Older Adults With DM >70 yrs Cognitive Dysfunction P <.002 Cognitively Intct Munshi M et l. Dibetes Cre. 2006;29: Helth nd retirement study (CDC). Munshi M et l. Dibetes Cre. 2006;29: Helth nd retirement study (CDC). Depression in Older Adults With nd Without DM Depressive Symptoms Associted With Risk of Functionl Disbility Men Women P<0.03 * Older Adults without DM Older Adults with DM 3 Without Depression With Depression Munshi M et l. Dibetes Cre. 2006;29: Helth nd retirement study (CDC). Munshi M et l. Dibetes Cre. 2006;29: Helth nd retirement study (CDC). Polyphrmcy Mrs. M: Age: 92 yers, leglly blind, 14 meds/dy Women Living Alone Glycemic control worsens s medictions tken increse Mediction Count Hyes M et l. Dibetes. 2006;908.

6 Mngement of Dibetes in Older Adults Screening for brriers Clinicl / functionl / psychosocil Mngement of hyperglycemi Medictions Diet Exercise / physicl ctivity Mngement of risk fctors BP control LDL cholesterol Cesstion of cigrette smoking -dose spirin therpy Yerly screening for microlbuminuri (ACE inhibitors), retinopthy, foot exmintion Glycemic Gol Optimize benefits Minimize hrm Hyperglycemi (A1C) Hypoglycemi Is A1C dependble mrker of glycemic control in older dults? A1C - 8.2% only Conditions commonly seen in elderly tht my ffect A1C levels Conditions Possible mechnisms Chnge in A1C Age Unknown Rce AA / Hispnic unknown Iron deficiency nemi RBC turnover Recent infection resistnce Trnsfusion RBC turnover Hemodilysis RBC life spn Erythropoietin therpy young RBC Metbolic cidosis / uremi Crbmyltion of hemoglobin Anemi of chronic diseses Unknown A1C - 8.3% nd orl Hypoglycemi in older dults therpy in older dults Frequent Hypoglycemic Episodes Detected by CGM ge>70 yrs; A1C>8%; n=40 Hypoglycemi unwreness Cognitive dysfunction interfering with identifiction/tretment of hypoglycemi Hypoglycemi & Fer of hypoglycemi Co-morbidities mimicking hypoglycemic symptoms Ptients with hypoglycemi n = 26 (65 %) Ptients with A1C 8-9 % 14 (54 %) Ptients with A1C > 9 % 12 (46 %) Severity of hypoglycemic episodes Noncomplince Flls, hospitl visits Excerbtion of chronic conditions Even mild hypoglycemi my result in poor outcome mg/dl 100 % mg/dl 73 % < 50 mg/dl 46 % Munshi et l; Arch Intern Med. 2011;171(4):

7 Ntionl Trends in US Hospitl Admissions for Hyper/Hypoglycemi Medicre Beneficiries Dibetes Cre Dec;35(12): J Am Geritr Soc Dec;60(12): Absolute risk of hypoglycemi; 100,000 ED dmissions /yer Lipsk et l; JAMA intern Med 2014; 174(7): Ptient chrcteristics /helth sttus Helthy - few co-existing illnesses - intct cognitive sttus - intct functionl sttus Complex/Intermedite - Multiple co-existing illnesses - Mild-moderte cognitive impirment - 2 IADL dependency Very Complex/Poor Helth - LTC cre residents - end-stge chronic illnesses - Moderte-severe cognitive impirment - 2 ADL dependencies A Frmework for Gols Consensus report (ADA) Rtionl A1C BP Lipids Longer life expectncy Intermedite life expectncy tretment burden Hypo vulnerbility Fll risk Limited life expectncy Benefits uncertin <7.5% <140/80 Sttins unless not tolerted <8% <140/80 Sttins unless not tolerted <8.5% <150/90 Consider risks nd benefits Kirkmn MS et l; Dibetes Cre Dec;35(12): Is it intuitive to liberte gols in older dults? Potentil Overtretment in Older dults NHANES: DM control cross helth sttus A1C<7% cross helth sttus Lipsk K et l; JAMA int med 2015;175;3; Gol-setting Algorithm in Elderly <7% Multiple Few Comorbidities Comorbidities or nd medictions Medictions tht my unlikely to cuse cuse hypoglycemi hypoglycemi Liberlize Gol/ chnge strtegy Present At gol with cution (Continully ssess for hypoglycemi) Medictions likely to cuse hypoglycemi Current A1c Crefully ssess for hypoglycemi or glucose excursions Not Present 7 8% Medictions unlikely to cuse hypoglycemi At Gol Present > 8% -Multiple Co-morbidities -Limited Life Expectncy -Difficulty coping Not Present Aim for Gol < 8% Use of serum c-peptide to simplify insulin regimen in older dults Norml/high serum C-peptide: 65/100 Age: 79±14 yrs, DM durtion: 21±13 yrs Number of medictions: 11 (rnge 4-18) Simplifiction completed in 35 ptients In 19 ptients, ptients completely off insulin In 16 ptients number of insulin injections were decresed significntly Number of hypoglycemic episodes decresed A1c improved from 8% to 7.4% (p<0.002) Munshi et l; Americn Journl of Medicine 2009;122;395-97

8 PPHG contribution (%) er contribution of post-prdil glucose in older dults 70 Cse of Mr. GB 22 u of bsl insulin with dinner nd sliding scre before ech mel <65 yers >65 yers 10 0 <7% 7-8% 8-9% >9% Hemoglobin A1C Munshi et l, J Am Geritr Soc. 2013;61: Age >70 yrs - 1 insulin injection/dy - stimulted c-peptide - 1 episode of glucose <70 Primry outcome: Secondry outcome: SIMPLE study de-intensifiction E v l u t i o n Active Intervention ( 5 months) Simplifiction of Regimen to Once dy Glrgine ± Non-insulin gents E v l u t i o n Independent Period (3 months) No Active Contct Durtion of hypoglycemi by CGM A1C E v l u t i o n Munshi et l, JAMA Intern Med 2016 July 1:176(7): Chnge timing from Bedtime to morning Algorithm for Regimen Simplifiction from bsl-bolus to one injection/dy Chnge or dd long-cting insulin If on Mixed insulin: Use 70% of the totl dose s bsl in the morning Titrte dose of bsl insulin bsed on FBS weekly mg/dl is s resonble gol in most pts My chnge gol bsed on overll helth If 50% of the FBS > gol, dose by 2 u If >2 fingerstick redings/wk re <80 mg/dl, dose by 2 u If mel-time insulin <10 u/dose: d/c nd dd non-insulin gents Bseline egfr Follow ADA guideline on dding Next gents Generl tips: -While djusting mel-time insulin My use simplified sliding scle, e.g. Premel glucose>250, give 2 u of short-cting insulin Premel glucose>350, give 4 u of short-cting insulin -Stop sliding scle when not needed dily -Do not use short-cting insulin t bedtime Chnge mel-time insulin If mel-time insulin >10 u/dose: 50% nd dd non-insulin gent Continue to titrte dose of meltime insulin down s non-insulin dose is incresed Munshi et l, JAMA Intern Med 2016 July 1:176(7): Mono- Therpy Dul Therpy Efficcy Hypo risk Weight Side effects cost Sulfonylure Moderte Gin Hypo Gin Edem, CHF DPP4-i Intermedite Neutrl rte SGLT2-i Intermedite Loss GU,dehydrtion GLP1 RA Loss GI (bsl) est Gin Hypo /vrible Simplifiction of insulin regimen improved hypoglycemi without worsening glycemic control Triple Therpy Efficcy Hypo risk Weight Side effects cost sulfonylure sulfonylure DPP4-i S= sulfonylure SGLT2-i sulfonylure sulfonylure (bsl) sulfonylure GLP1RA Combintion with injectble Bsl insulin or mel-time insulin or Durtion of hypoglycemi <70 / 5-dy CGM A1C % dpted from Dibetes Cre 2015;38: Munshi et l, JAMA Intern Med 2016 July 1:176(7):1023-5

9 8- Months 8 Month 5- Months 5 Month Screening Screening A1c 7.4% Time<70: 130 mins mixed insulin 70/30 70 units QAM, 45 units QPM metformin 500mg BID A1c 9.9% Time < 70 mg/dl: 240 min detemir 30 u q m nd 50 u q hs rpid-cting sliding scle preprndil & HS A1c 7.0% Time<70: 75 mins glrgine 66 units QAM, 1000mg BID, glipizide 10mg BID A1c 10.2% Time < 70 : 40 min glrgine 98 units QAM, Glipizide 10mg BID lirglutide 1.8mg QAM 8month A1c 7.0% Time <70: 0 mins glrgine 66 units QAM, 1000mg BID, glipizide 10mg BID A1c 8.7% time<70: 375 mins glrgine 50 units QAM, 56 units QPM, Glipizide 10mg BID lirglutide 1.8mg 5month QAM, rpid-ctign sliding scle Tble 3 A: Chnge in Hypoglycemi durtion nd A1C in groups with different A1C t bseline Bseline A1C 7% % % >9% N=17 N=27 N=14 N=7 Hypo Durtion (mins/5 dys) <70 mg/dl 292± ± ± ±222 <60 mg/dl < 50 mg/dl Chnge in A1C Bseline 5 months 0.37± ± ± ±2.0 P =0.03 P= 0.8 P= P=0.03 Bseline 8 months 0.48± ± ± ±1.4 P =.04 P= 0.3 P= 0.3 P= 0.2 Tble 3b: Durtion of hypoglycemi by A1C levels t 5 months nd 8 months 5-month A1C 7% % % >9 % N=18 N=28 N=11 N=3 Hypo durtion (mins/5 dys) <70 mg/dl 103 ± ± ± ± 153 <60 mg/dl < 50 mg/dl month A1C 7% % % >9 % N=11 N=25 N=15 N=4 Hypo durtion (mins/5 dys) <70 mg/dl <60 mg/dl < 50 mg/dl Summry Older vs Younger Unique chrcteristics of the popultion Older dults re heterogeneous popultion Aging is ssocited with Homeostenosis nd presence of comorbidities Complexity of the gol-setting - Avoid dependence on A1C s the sole prmeter - Risk fo hypoglycemi should be crefully ssessed Effective strtegies for tretment Avoid overtretment De-intensify nd mtch ptient s coping bilities with tretment complexity Munshi MN et l; J dib nd its Compl, July, 2017, Vol 31; 7; cc Aging Successfully Geritricin s Serenity Pryer Wisdom to know when not to mess with it!