Diabetes in Older Adults

Transcription

1 Diabetes in Older Adults Karin Willis, MD UND Center for Family Medicine, Bismarck March 31, 2017 Demographics From 1995 to 2004 Prevalence of type 2 diabetes in nursing home residents increased 16% to 23% In 2012 Prevalence (across multiple studies) ranged from 25-34% A 4.5-fold projected increase in diagnosed diabetes in those aged >65 by 2050 Increasing incidence and detection, decreasing mortality, and aging of the Baby Boomers contribute to the increase in diabetes prevalence over the next 2-3 decades 1

2 Pathogenesis of Diabetes in Older Adults Poor nutrition Genetics Medications Reduced insulin secretion Increased adipose tissue Decreased physical activity Diagnostic Criteria for Diabetes and Prediabetes in nonpregnant adults Normal High Risk for Diabetes Diabetes FPG <100 mg/dl FPG mg/dl FPG 126 mg/dl 2-h PG <140 mg/dl 2-h PG mg/dl 2-h PG 200 mg/dl A1C < 5.5% A1C % A1C >6.5% ** American Association of Clinical Endocrinologists / American College of Endocrinology (April 4, 2015) 2

3 Demographics Same spectrum of macrovascular and microvascular complications risks as their younger counterparts High risk for Polypharmacy Functional disabilities Cognitive impairment Depression Falls with injury Persistent pain Urinary incontinence Is intensive glycemic control recommended for older adults? 50% 50% No Ye s A. Yes B. No 3

4 Management Goals in Older Adults Primary goal of diabetes management for older adults ACHIEVE A BALANCE Optimal glycemic control to slow/prevent disease complications VS Avoiding hypoglycemia and its consequences Heterogenous population Strategy must account for disparities in health and ability: Living independently in communities VS Assisted care facilities VS Nursing homes Fit and healthy VS Frail with many comorbidities 4

5 Glycemic Goals Few data specifically addressing optimal glycemic targets in older adults Should be based on patient s overall health and predicted period of survival Risk of complications is duration-dependent In absence of long-term clinical trial data, the following glycemic goals have been adapted from the American Diabetes Association Should older adults be placed on a statin? 33% 33% 33% de pe nd s It No Ye s A. Yes B. No C. It depends 5

6 Glycemic Goals Healthy Adults A1C <7.5 Few co-existing chronic illnesses (serious enough to require medication or lifestyle management, e.g. arthritis, cancer, CHF, depression, COPD, falls, chronic renal failure) Intact cognitive status Intact functional status Fasting/Postprandial glucose: mg/dl Bedtime glucose: mg/dl BP: <140/90 Statin (unless not tolerated) Glycemic Goals Complex/Intermediate Health A1C <8 Multiple co-existing chronic illnesses Mild-moderate cognitive impairment 2+ IADLS * Fasting/Postprandial glucose: mg/dl Bedtime glucose: mg/dl BP: <150/90 Statin (unless not tolerated) * Instrumental Activities of Daily Living: functioning in travelling, shopping, housework, managing finances, using the telephone, taking medications 6

7 Glycemic Goals Very Complex/Poor Health A1C <8.5 LTC care residents End-stage chronic illnesses Moderate-severe cognitive impairment 2+ ADL** dependencies Fasting/Postprandial glucose: mg/dl Bedtime glucose: mg/dl BP: <150/90 Consider stopping statin if expected longevity less than 1 year ** Activities of Daily Living: measures the 5 basic functions of bathing, toileting, dressing, transferring, and eating Rationale for Varying Goals Life expectancy Hypoglycemia vulnerability = Traumatic falls and exacerbation of comorbid conditions Fall risk Uncertain benefits of tight glycemic control in advanced stages of poor health Goals are consistent with the American Geriatrics Society (AGS), the American Diabetes Association (ADA), the International Diabetes Federation (IDF) and the European Diabetes Working party guidelines 7

8 ACCORD Trial 2008 Action to Control Cardiovascular Risk in Diabetes (ACCORD) Randomized 10,251 patients with long-standing type 2 diabetes to either intensive (A1C <6%) or standard glycemic control (A1C 7-7.9%) Trial stopped early (3.7 years) because intensive glycemic control was associated with increased all-cause and CV mortality Suggests that intensive therapy in persons at high risk for CVD, and especially polypharmacy may be at increased risk A1C Measurement A1C may be inaccurate in several common situations seen in older adults (conditions that shorten erythrocyte survival or decrease mean erythrocyte age) Anemia (acute blood loss, hemolytic) falsely lower A1C Iron deficiency anemia falsely higher A1C Chronic kidney disease a number of confounding variables affect this Recent transfusions Erythropoietin infusions and IV iron falsely lower A1C Recent acute illness or hospitalization Chronic liver disease Alternative forms of testing: glycated serum protein or glycated albumin Incumbent on the clinician to know when A1C result should be questioned, e.g. when value at variance with patient s self-monitoring blood glucose values or if there has been an acute change in A1C 8

9 What are 3 risk factors for hypoglycemia in the older adult? Avoiding Hypoglycemia Recent studies suggest that hypoglycemia poses significant health threats to older adults Glucose-lowering agents have been implicated in onefourth of emergency hospitalizations for adverse drug events in older adults, nearly all of them for hypoglycemia Hospital admissions for hypoglycemia surpass those for hyperglycemia among Medicare beneficiaries Even mild hypoglycemia may lead to adverse outcomes Dizziness, weakness Equals falls with fractures 9

10 Avoiding Hypoglycemia Older adults tend to have more neuroglycopenic manifestations of hypoglycemia Dizziness Weakness Confusion / disorientation /delirium Poor concentration and coordination May be misconstrued as primary neurologic, e.g. TIA Avoiding Hypoglycemia Hypoglycemia may increase risk of adverse CV events cardiac autonomic dysfunction / cardiac autonomic neuropathy (CAN) Most common in patients with diabetes A serious medical condition that creates instability in HR control + complications with central and peripheral vascular dynamics Linked to a significantly greater risk of mortality to autonomic performance of the heart. Patients with CAN often experience asymptomatic (silent) ischemia, MI, decreased likelihood of survival after MI Symptoms may be subtle and occur late in the course of diabetes Symptoms include abnormal exercise-induced CV performance, postural hypotension, cardiac denervation syndrome Complex reflex pathways Formal CV stress testing may be prudent before initiating and exercise program in such patients 10

11 Medications to use with caution ** To avoid hypoglycemia, particularly in frail older adults Insulin secretagogues, e.g. sulfonylureas and meglitinides All types of insulin Hyperglycemia Persistent hyperglycemia Increases risks of Dehydration Electrolyte abnormalities Urinary incontinence Dizziness Falls Hyperglycemic hyperosmolar syndrome 11

12 What is the leading cause of death in older adults with diabetes? Cardiovascular Risk Reduction Absolute CVD risk much higher than in younger adults Both diabetes and age are major risk factors for coronary artery disease Heart disease is the leading cause of death by far in older patients with diabetes No good studies on how to reduce this risk specifically in the older population As with glycemic control, benefit of CV risk reduction depends on patient s frailty, overall health, and projected survival 12

13 Name 3 ways to reduce cardiovascular risk in older adults? Cardiovascular Risk Reduction Areas of focus Smoking cessation Treatment of hypertension Treatment of hyperlipidemia Aspirin therapy Exercise 13

14 Statin Therapy Recommend use of a statin unless contraindicated to lower cholesterol ACCORD Trial: No benefit to adding a fenofibrate to statin therapy in diabetes patients who were high risk Keep in mind: Statins reduce risk of CV events quickly, within weeks to months, so can have significant benefits even in patients with reduced lifesspan Goals for lipid management should be adjusted based on Life Expectancy Comorbidities Cognitive Status Personal preferences Is taking a daily aspirin more beneficial in reducing CV risk in patients LESS than age 65 or those older than 65? 50% 50% No Ye s A. Yes B. No 14

15 Aspirin Therapy Daily aspirin to reduce macrovascular disease Meta-analysis of a large number of secondary prevention trials: Absolute benefit of aspirin greatest in those over 65 years with diabetes or diastolic hypertension Exercise Helps maintain physical function Reduces cardiac risk Improves insulin sensitivity Improves body composition and arthritic pain Reduces falls and depression Increases strength and balance Enhances quality of life Improves survival 15

16 Exercise Studies of frail older adults support: Weight training should be included in addition to aerobic exercise Referral to exercise physiologist of physical therapist for muscle strengthening and balance training in a safe environment (if indicated) New Diagnosis of Hyperglycemia: Initial Treatment Nutrition Physical activity Optimizing glycemic control Preventing complications Weight reduction through diet, exercise, and behavioral modification 16

17 What is the first medication you would choose for a newly diagnosed diabetic if A1C was <9.0? Metformin Should be initiated at time of diabetes diagnosis May first do 3-6 month trial of lifestyle modification if patient wishes to avoid medication If contraindications to metformin, consider shortacting sulfonylurea (glipizide) as an alternative 17

18 Should you attempt to put your patient in the nursing home or other long-term care facility on a diabetic diet? 50% 50% A. Yes B. No No Ye s Why, or why not? Medical nutrition therapy Therapeutic approach to treating medical conditions Diet devised and monitored by a medical doctor, registered dietitian or professional nutritionist Diet is based on patient s medical history, physical exam, functional exam, dietary history Goal: To reduce the risks of developing complications in pre-existing conditions, such as type 2 diabetes 18

19 Medical Nutrition Therapy In a randomized trial of MNT in adults >65 years of age, intervention group had significantly greater improvements in fasting plasma glucose (-18.9 vs -1.4 mg/dl) and A1C (-0.5 percentage points vs no change) than control patients. Medical Nutrition Therapy Challenges to be considered before developing meal plans: Altered taste Coexisting illnesses and dietary restrictions Compromised dentition Altered GI function Difficulty with food shopping and preparation Memory decline leading to skipped meals In general, avoid complex dietary and treatment regimens 19

20 Medical Nutrition Therapy Restrictive therapeutic diets should be minimized Liberal diet plans are associated with improved food and beverage intake, and avoidance of: Dehydration Unintentional weight loss / decreased food intake While carbohydrate intake should be taken into consideration, no concentrated sweets or no sugar diet orders are ineffective for glycemic management and are not recommended. Medical Nutrition Therapy Other considerations Obesity May benefit from caloric restriction Increase physical activity Goal weight loss: approximately 5% pf body weight Undernutrition Weight loss increases risk of morbidity and mortality in older adults Unintentional weight loss 20

21 Metformin What are its most important 1. Benefits? 2. Side effects? 3. Contraindications? And How often should you monitor renal function in older adults? Medication Metformin Reduces hepatic gluconeogenesis; decreases intestinal glucose absorption, enhances sensitivity to insulin Contraindications, e.g. renal impairment, acute CHF GFR must be >30 ml/min Reduce dose no more than 1,000 mg/d for GFR ml/min Likely to safely reduce glycemia at any level May reduce progression of hyperglycemia 21

22 Metformin May reduce likelihood of developing diabetes-related complications Low risk of hypoglycemia Side effects: GI upset, lactic acidosis (increased risk in case of MI, stroke, pneumonia, heart failure); stop taking if become ill for any reason, of if undergoing procedure requiring iodinated contrast Monitor renal function every 3-6 months, rather than annually Sulfonylureas What are their most important 1. Benefits? 2. Side effects? 3. Contraindications? And How often should you monitor renal function in older adults? 22

23 Sulfonylureas Use if contraindication or intolerance to metformin Lower glucose primarily by stimulating insulin release from pancreatic beta cells. Use short-acting, e.g. glipizide Glyburide is not recommended in cases of renal dysfunction as most likely to accumulate and cause hypoglycemia Benefits: universally available, efficacy in lowering glucose, low cost Risks: hypoglycemia, weight gain Long-acting sulfonylurea drugs -- chlorpropamide, glyburide, and glimepiride more likely to cause severe, prolonged hypoglycemia Meglitinides Starlix (nateglinide), Prandin (repaglinide) Stimulate pancreatic islet beta cell insulin release Require more frequent administration (with meals), and are more expensive than sulfonylureas Because pharmacologically distinct from sulfonylureas, may be used if allergy to sulfonylureas Principally metabolized by the liver; may be considered as initial therapy in patient with CKD Because of their short-acting nature, should be taken to prior meals, and skipped if patient omits a meal Therefore, may be challenging for older patients, esp if have an organized pillbox 23

24 Insulin What are its most important 1. Benefits? 2. Side effects? 3. Contraindications? Insulin May be considered as initial therapy for all patients, but esp those presenting with: A1C >9 percent Fasting plasma glucose >250 mg/dl Random glucose consistently >300 mg/dl Ketonuria 24

25 Insulin Stimulates peripheral glucose uptake, inhibits hepatic glucose production, inhibits lipolysis and proteolysis, regulating glucose metabolism Risk category for hypoglycemia: moderate to severe Side Effect: weight gain, hypoglycemia Medications Few data specifically addressing drug therapy in older patients In general, oral and injectable agents with low risk of hypoglycemia are preferred in older adults Pharmacologic therapy should be individualized based patient: Abilities Comorbidities Start low, go slow 25

26 Drug-induced hypoglycemia More likely to occur: After exercise or a missed meal If eating poorly or abusing alcohol If impaired renal or cardiac function or GI disease During therapy with salicylates, sulfonamides, fibric acid derivatives (e.g. gemfibrozil) and warfarin Evaluate side effects of any medications, esp hypoglycemic episodes, at each visit DDP-4 inhibitor What are its most important 1. Benefits? 2. Side effects? 3. Contraindications? 26

27 DDP-4 inhibitors Examples: Januvia (sitagliptin), Galvus (vildagliptin), Onglyza (saxagliptin), Tradjenta (linagliptin), Nesina (alogliptin) Inhibits dipeptidyl peptidase-4, slowing incretin metabolism, increasing insulin synthesis/release, decreasing glucagon levels Once a day oral agents No risk of hypoglycemia, weight-neutral Usually lower A1C levels only by 0.6 percent (similar to sulfonylurea) Long-term safety not established, relatively expensive Hyperglycemia If glycemic goals not met with single agent, evaluate for contributing causes: Side effects Poor understanding of the nutrition plan Difficulty following medication regimen Pill dispensers Family members or caregivers to help administer medication 27

28 Name four age related factors that can affect the management of diabetes in older adults. Age-Related Challenges to Diabetes Control Altered senses Difficulties in preparing/eating food Decreased mobility/exercise Altered renal/hepatic function Altered circulation Co-morbidities Polypharmacy Social changes Unintentional weight loss 28

29 Hyperglycemia Addition of basal insulin carefully titrated to avoid hypoglycemia Combination of other medications that can be used with a sulfonylurea: DPP-4 inhibitors, GLP-1 agonists, sodiumglucose co-transporter 2 (SGLT2) inhibitors, alpha glucosidase inhibitors Hyperglycemia Dual agent failure: Consider starting or intensifying insulin therapy In patients on sulfonylureas and metformin who are starting insulin therapy, sulfonylureas are generally tapered and discontinued, while metformin is continued Another option: 2 oral agents + GLP-1 receptor agonist 29

30 GLP-1 inhibitor What are its most important 1. Benefits? 2. Side effects? 3. Contraindications / Cautions? GLP-1 receptor agonist Examples: Byetta/Bydureon (exenatide), liraglutide (Victoza, Saxenda), albiglutide (Tanzeum), dulaglutide (Trulicity) Activates glucagon-like-peptide-1 (GLP-1) receptor, increasing insulin secretion, decreasing glucagon secretion, and delaying gastric emptying (incretin mimetic) Reasonable to try a GLP-1 agonist before starting insulin in patients who are close to glycemic goals, who prefer not to start insulin, and who are okay with weight loss Disadvantages: Requires injection, frequent GI side effects, expensive 30

31 Insulin initiation With availability of long-acting insulins, has become easier to use once-daily long-acting insulins monotherapy or add once-daily insulin to oral hypoglycemic medications Considerations: Is patient physically and cognitively capable of: using insulin pen or drawing up and giving appropriate dose monitoring blood glucose recognizing and treating hypoglycemia Pharmacist or family member may prepare week s supply of insulin in syringes and leave in refrigerator Insulin initiation Start with morning long-acting insulin Adjust dose once weekly to reach target fasting blood sugar Need less insulin in chronic kidney disease because insulin metabolism is altered 31

32 Is sliding scale insulin recommended for use in treatment of hyperglycemia in long-term care facilities? A. Yes B. No 50% 50% No Ye s Why, or why not? Sliding Scale Insulin NO Recently added to Beers Criteria for Potentially Inappropriate Medication Use in Older Adults Leads to wide blood glucose deviations A burden for patients A burden on nursing time and resources No clearly defined practical guide to switch patients admitted to LTC from SSI to basal-bolus insulin 32

33 Monitoring glycemia A1C Quarterly in patients not meeting glycemic goals Twice yearly in those meeting treatment goals Blood glucose monitoring Self-monitoring (patient or caregiver) In select older patients Esp if on medications that can cause hypoglycemia If patient would take action to modify eating or exercise or willing to intensify pharmacotherapy, based on results May not need if diet treated or oral agents not associated with hypoglycemia Macrovascular Complications Screening similar to younger patients Retinopathy, nephropathy, foot problems Complications that impair functional capacity (e.g. retinopathy, foot problems) identify and treat promptly Poor vision = social isolation, risk of accidents, inability to measure blood glucose, draw up insulin doses 33

34 What ophthalmologic complications do you see more commonly in older diabetic patients compared to older NON-diabetic patients and younger patients? Should you check a urine microalbumin on older patients if they are already on an ACE inhibitor or ARB? 50% 50% No Ye s A. Yes B. No 34

35 Screening Ophthalmologic exam: (Annually) Screen for diabetic retinopathy Cataracts and glaucoma Both more common in older diabetic patients VS nondiabetic patients Cataracts: more than twice as common in people >65 years with diabetes VS similarly aged nondiabetic patients (38.4 % vs 16.6%) Nephropathy Prevalence of increased urinary albumin excretion increases in older population for reasons unrelated to diabetic nephropathy If already taking an ACE inhibitor or ARB Limited value in continuing testing for increased urinary albumin excretion on an annual basis Screening Foot problems Important cause of morbidity Risk is much higher in older diabetic patients vs younger Estimated that prevalence of diabetic neuropathy in patients with type 2 diabetes is 32% overall, and more than 50% in patients over 60 years More than 30% of older diabetic patients cannot see or reach their feet (cannot inspect) Older diabetic patients should have their feet examined at every visit If unable to do self foot exam, inquire if family member or friend could do routine foot inspections Give prophylactic advice on foot care for those at high risk 35

36 Common Geriatric Syndromes (associated with diabetes) Cognitive impairment Diabetes is associated with increased risk of dementia Difficulty performing self-management and following complicated treatment regimens Assess cognitive function esp if: Nonadherence to therapy Frequent episodes of hypoglycemia Deterioration of glycemic control with no obvious explanation Common Geriatric Syndromes (associated with diabetes) Depression Early identification (ex geriatric depression scale) Polypharmacy Keep medication list current, and review at each visit Urinary incontinence Increased risk in women with diabetes Identification and treatment to improve quality of life 36

37 Common Geriatric Syndromes (associated with diabetes) Falls Multifactorial Peripheral and/or autonomic neuropathy Muscle weakness Functional disability Vision loss Polypharmacy Osteoarthritis Even mild hypoglycemia Nursing Home Patients Few studies and guidelines re: care of older diabetics residing in NH Management goals should be based on: Life expectancy Quality of life Functional ability Co-existing conditions Exercise in any form good for all 37

38 Mottos Final Thoughts Take a balanced approach. Benefits of improved glycemic control / Possible increased risk of falls Look at the total person. Start low. Go slow. Keep it Simple. References Medha N. Munshi, et al. 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): American Association of Clinical Endocrinologists and American College of Endocrinology Clinical Practice Guidelines for Developing a Diabetes Mellitus Comprehensive Care Plan Endocr Pract. 2015;21 (Suppl 1). David K McCulloch, MD; Medha Munshi, MD. Treatment of type 2 diabetes mellitus in the older patient. UpToDate. Jan