N ovel Strategies to M anage D iabetes in O lder A dults

Transcription

1 N ovel Strategies to M anage D iabetes in O lder A dults M edha M unshi, M.D. Beth Israel D eaconess M edical Center Joslin Diabetes Center Harvard M edical School Goals and Objectives Unique aspects of presentation: Young vs. older adults with diabetes Co-morbidities and barriers associated with diabetes Approach for management of diabetes in older adults

2 Current and Projected Prevalence of Diabetes in the U.S % Prevalence Yrs Yrs >75 Yrs Venkat Narayan et al from CDC; Diabetes Care Sept 2006 Young adults vs Older adults Diabetes Heterogeneous population Clinically Functionally Socioeconomically Multiple co-morbidities Goals of treatment Medication management Education strategies Heterogeneity in An Older Adult With Diabetes Community living Assisted care facilities Nursing home Alone spouse Highly functional Functionally disabled Other Family member Older adult With diabetes

3 Co-morbidities in Aging and Diabetes Aging Macro/Micro vascular dz Cognitive dysfunction Depression Physical disability Polypharmacy Diabetes Cognitive Dysfunction Executive 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 YOM Engineer computer savvy DM duration 17 yrs Glargine bid and lispro before meals A1c 6.5%

4 % Patient with cognitive dysfunction Case History: Mr. M 77 YOM Diabetes duration - 61 years A1c- 6.6% Treated by Dr. Eliot Joslin at diagnosis. He remembers Dr. Joslin telling him to avoid highs at all cost BMI 17.6 Insists that he feels fine when BGs are very low but feels lousy when they are high Instruction Form: Response Form: Modified Clock-In-a-Box(CIB) 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 Cognitive Dysfunction in Older Adults With and Without DM Older adults without DM Older adults with DM >70 yrs Munshi et al; Diabetes Care 2006 Health and retirement study (CDC)

5 IADL (total score) Percent Cognitive Dysfunction Associated With Poor Diabetes Control Hemoglobin A1c cognitive dysfunction cognitively intact P<0.002 Munshi et al; Diabetes Care; Aug 2006 Depression in Older Adults with and without DM Men Women 5 0 Older adults without DM Older adults with DM Munshi et al; Diabetes Care 2006 Health and retirement study (CDC) Depressive Symptoms Associated with Increased Risk of Functional Disability P< * Without Depression With Depression Munshi et al; Diabetes Care 2006

6 Case History Mrs B is a 78 yrs old pt with excellent control of diabetes for 14 years managed on oral agents. She was a primary caregiver for her husband. Mr. B was recently institutionalized for dementia. She is found to have deteriorating BS control at the next visit. While testing for depression, pt became tearful. She mentioned that she has stopped watching her diet, skips meals- hates to cook for herself, does not exercise and avoids getting out of the house. Functional Impairment in 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 For Women Living Alone, Glycemic Control Worsens as Medications Taken Increases HbA1c Medication Count Hayes et al; Diabetes: 908-P: 2006

7 Complex Interactions in Older Adults with Diabetes Morbidity and Functional Disability Hypoglycemia Compliance Quality of life CAD CVD PVD Cognitive Dysfunction Depression Poly pharmacy Neuropathy Retinopathy Nephropathy Falls Urinary Incontinence Physical Disability Diabetes Mellitus Morbidity Mortality Management of Diabetes in Older Adults 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 Screening and management of co-morbidities Goal- Setting Glycemic Control Hypoglycemia Social support Living situation Financial issues Life expectancy Physical abilities

8 Goal- Setting Glycemic Goal Overall Health Goal Hypoglycemia in older adults Insulin therapy in older adults Hypoglycemia unawareness Cognitive dysfunction interfering with identification/treatment of hypoglycemia Co-morbidities mimicking hypoglycemic symptoms Hypoglycemia & Fear of hypoglycemia Noncompliance Falls, hospital visits Exacerbation of chronic conditions Even mild hypoglycemia may result in poor outcome Continuous Glucose Monitoring

9 Diagnosis Lifestyle intervention Metformin Life style metformin Basal insulin Life style metformin Sulfonylurea Life style metformin intensive insulin STEP 1 STEP 2 STEP 3 Algorithm for the metabolic management of type 2 diabetes Life style metformin Pioglitazone No hypoglycemia Edema/CHF Bone loss Life style metformin GLP-1 agonist No hypoglycemia Weight loss Nausea/vomitting Life style metformin Pioglitazone Sulfonylurea Life style metformin Basal insulin Nathan et al; Diabetes care;32;1;2009 Considerations in Elderly Patients > 80 years of age Renal insufficiency Risk of intra vascular dehydration Avoid Metformin Initial therapy with Glitazone, GLP-1 agonist or Sulfonylurea Considerations in Elderly Hypoglycemia unawareness Inability to recognize or treat hypoglycemia Irregular/unreliable eating pattern Avoid sulfonylurea Consider alternate agents or nonsulfonylurea secretagogues

10 Considerations in Elderly CHF class 3-4 CAD Leg edema Bone loss Avoid Glitazone Other Agents Advantages Disadvantages Use in elderly Exenatide (GLP-1 analogue) Pramlinitide (anlogue of human Amylin) -no hypo -weight loss -sc injection -weight loss -Limited -Obese young elders Not clear in elderly -sc injection Not clear Sitagliptin (DPP-4 inhibitor) -no hypo -weight neutral -Very new -expensive -As initial agent or as additional agent without significant side effects Types of insulin

11 Initiation and Adjustment of Insulin regimen Bedtime Intermediate or long-acting 10 u or 0.2u/kg Check FBS >130-2 u q 3 days >180-4 u q 3 days Hypoglycemia or FBS<70 Lower bedtime dose 4 u or 10% No Check A1c q 3 months A1c 7% after 2-3 months Yes FBS in target range-check premeal BS Add 2 nd injection at 4 units with adjustment Pre lunch high BS Rapid acting at breakfast Pre dinner high BS NPH at breakfast or Rapid acting at lunch Pre bedtime high BS Rapid acting at dinner No A1c 7% Nathan et al; Diabetes Care;32:1;2009 Check pre meal BS and add another injection Check post prandial BS and adjust pre meal injection Strategies Used at the Geriatric Diabetes Clinic Health Literacy 2 question screening Cognitive assessment CIB Depression 2 question tool Functional assessment - questionnaire Social support assessment - questionnaire Medication adherence and Polypharmacy assessment Nutrition assessment 6 questions tool Exercise prescription pt tolerance and preference Geriatric Diabetes Clinic Goals: Identify barriers Help patients to overcome barriers depression, deconditioning, social isolation Modify management plans to accommodate barriers cognitive dysfunction, physical disabilities Improve overall health and quality of life along with glycemic goals

12 Patient History Mr. GD Age: 83 years old Gender: male Diabetes duration: 12 years Comorbidities: hypertension, hyperlipidemia, arthritis, retinopathy, and neuropathy Lives alone since wife passed away 6 months ago. Two caring children live in California Two minor episodes of hypoglycemia in past month felt dizzy but treated promptly with orange juice BMI: 27 Has lost 10 lbs in past year with poor appetite BP: 110/60 Patient History Medications Glipizide 10 mg Q am Glucophage 1000 mg BID Lisinopril, metoprolol, and HCTZ for high blood pressure Aspirin 81 mg/day Simvastatin 40 mg/day Gabapentin 100 mg TID Two different types of eye drops Acetaminophen 500 mg QID One multivitamin for seniors Vitamin D 800 IU/day Patient History Laboratory data A1C = 8.7% Total cholesterol = 190, LDL = 105 Treatment Patients says he is compliant with medications Unable to walk owing to arthritis and afraid of falling; he fell once on an uneven sidewalk while walking Has been following same diet for many years but isn t as hungry as he used to be Glucometer monitoring: highly fluctuating blood glucose from 70 to 300 at different times

13 Case History: Patient GD Differences in Assessments Diabetes team: Elevated A1C level LDL is not within goal Poor vision Overweight Two episodes of mild hypoglycemia treated appropriately Geriatric diabetes team: HYPOGLYCEMI: May lead to traumatic fall and fracture, esp. in light of coexisting conditions Unintended weight loss Screening shows depressive symptoms Mild cognitive dysfunction on screening- medication adherence Deconditioning owing to no physical activity, leading to fear of fall? Too tight control of BP 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 Munshi et al; American Journal of Medicine 2009;122; Simplification of Insulin Regimen Munshi et al; American Journal of Medicine 2009;122;395-97

14 Simplification of Insulin Regimen Clinical significance 1. Older adults with long duration of diabetes, on insulin therapy, may have preserved endogenous insulin production as seen by detectable serum c-peptide level. 2. Serum c-peptide levels can be used to guide simplification of the diabetes regimen in older adults who have difficulty coping with a complicated insulin regimen. 3. The simplification of the diabetes regimen may lead to reduced risk of hypoglycemia without compromising glycemic control Munshi et al; American Journal of Medicine 2009;122; Algorithm for simplifying insulin regimen in older patients Difficulty coping with treatment regimen Measure serum c-peptide Normal/high C-peptide Consider age and hypoglycemia Younger age Stable renal function Add metformin with meals Titrate dose to replace bolus injection Watch renal function Watch for weight loss, N/V, anorexia Hypoglycemia not major concern; Stable health & eating pattern Metformin not tolerated Add sulfonylurea at mealtime Titrate dose to replace bolus injection Assess periodically for hypoglycemia Frail/older patient High risk of hypoglycemia, Cognitive dysfunction No CHF, Normal LFT Add glitazone insulin dose in 2-6 wks based on SMBG May add another agent based on SMBG Add 2 nd agent or switch to alternate agent or add newer agents like sitagliptin Algorithm for simplifying insulin regimen in older patients Difficulty coping with treatment regimen Measure serum c-peptide Low C-peptide or Unable to tolerate orals Consider cognitive function, physical ability, caregiver support Twice a day am/hs NPH to control fasting and pre-supper readings Mixed dose 70/30 or 75/25 at breakfast and supper Fixed dose bolus premeal instead of sliding scale and once a day basal

15 Summary winning the battle as well as the war Older patients with diabetes is a heterogeneous group Older adults have multiple co existing conditions that interfere with their ability to perform self-care It is important to set and adjust goals of treatment in older adults. (A1c should not be the only indicator for goal setting) Simplification of regimen is needed to accommodate barriers in older adults Clinical guidelines for the care of older adults with diabetes at Joslin Geriatric Diabetes Team Research Team Emmy Suhl, MS, RD, CDE Laura Desrochers, BS Patty Bonsignore, RN, CDE Adrianne Sternthal, BA Judy Giusti, MS, RD, CDE Katie Weinger, EdD Clinical Team Alissa Segal, PharmD, CDE Elizabeth Staum, MS, RD