Janice Lazear, DNP, FNP-C, CDE DIAGNOSIS AND THE OLDER ADULT

Transcription

1 Janice Lazear, DNP, FNP-C, CDE DIAGNOSIS AND THE OLDER ADULT

2 Objectives u At conclusion of the presentation the participant will: 1. Discuss challenges to glycemic control unique in the older population with diabetes. 2. Describe principles of medication management for older adults with diabetes.

3 Diabetes and the Older Adult Scope of the Problem u Fastest growing segment of the population à > 85 years of age US Diabetes incidence > age 65 u 10.9 million 26.9% u 1/3 of older adults with diabetes are undiagnosed u Older adults have the highest prevalence of complications u MIs u End-stage-renal disease u Visual impairment u Lower extremity amputations u Diabetes related hospitalizations

4 Scope of the Problem u Higher morbidity and mortality compared to elderly people without diabetes u ~ $245 billion spent yearly on diabetes u $144.5 billion (59%) was for care for the elderly

5 CDC Projections u Centers for Disease Control and Prevention (CDC) u Even if diabetes incidence rates level off, the prevalence of diabetes will double in the next 20 years, in part due to the aging of the population.

6 Physiological Alterations u Older adults with diabetes u More likely to have normal fasting hepatic glucose production u Abnormal insulin secretion beta cell dysfunction u Alterations in insulin release u Loss of first phase insulin secretion u Decreased response to incretin hormones u Decreased insulin sensitivity u Higher body fat content u Loss of fat free mass u Central distribution of fat

7 First phase of insulin

8 Incretin Hormones

9 Clinical Presentation u Renal threshold for glucose increased u Glycosuria may not be detected u Polydipsia may be absent due to an impaired thirst mechanism u Increased risk of dehydration u Increased risk of nonketotic hyperosmolar state u u Clinical presentation u Infections u Neuropathic pain u Weight loss

10 Characteristics of Diabetes in Older Adults u Incidence of diabetes increases until age 65 then levels off u Older adults with diabetes u Onset in middle age or earlier u More likely to have retinopathy u Onset in later years u More common in non-hispanic whites u Lower mean A1C and decreased use of insulin u Cardiovascular disease or peripheral neuropathy u Not influenced by age of onset

11 Complications in Older Adults u Highest rates than other age groups: u Major lower-extremity amputation u Myocardial infarction u visual impairment u end-stage renal disease u Aged 75 years have u higher rates than those aged years for most complications u Deaths from u ED visits for hypoglycemia u Twice as high as visits in the general population with diabetes

12 The Action to Control Cardiovascular Risk in Diabetes (ACCORD) Trial u Study Population u N = 10,251 patients with T2DM u Mean age 62.2 years of age u Median A1C 8.1% u Assigned to intensive therapy target A1C < 6.0% Or u Standard therapy target A1C from 7.0 to 7.9% u Primary study outcome a composite of: u Nonfatal MI u Nonfatal stroke u Death from cardiovascular causes

13 The ACCORD Trial u The finding of higher mortality in the intensive-therapy group led to a discontinuation of intensive therapy after a mean of 3.5 years of follow-up.

14 The Action in Diabetes and Vascular Disease (ADVANCE)Trial u Intensive Blood Glucose Control and Vascular Outcomes in Patients with Type 2 Diabetes u Study population u N = 11,140 patients with type 2 diabetes u Randomized to intensive treatment (A1C 6.5%) and standard care (A1C 7.3%) u Composite outcome macrovascular and microvascular complications

15 ADVANCE Trial u No increased mortality in the intensive treatment group u Renal Complications 1/5 reduction in renal complications u Composite outcome reduced mainly due to the reduction in renal complications u No separate reduction in macrovascular complications

16 ADVANCE Trial u Primary Outcomes u Composites of: u Major macrovascular events u Death from cardiovascular causes, nonfatal myocardial infarction, or nonfatal stroke u Major microvascular events u New or worsening nephropathy u New or worsening retinopathy

17 ADVANCE Outcomes u ADVANCE u trial resulted in a reduction by one fifth in the u development of new or worsening nephropathy u and a more modest, though significant, reduction in that of newonset microalbuminuria.

18 the Veterans Affairs Diabetes Trial VADT u Intensive glucose control u No statistically significant effect on major CV events or death u Significant reductions in albuminuria

19 Prevention of Diabetes Diabetes Prevention Program Research Group (DPP) u 20% of participants were aged 60 years u Lifestyle intervention more efficacy than in younger groups u No benefit to Metformin u 10 year follow-up u 49% risk reduction in those aged > years of age vs 34% in general study population

20 Environmental Impact Diet u Simple sugars u Saturated fat u Total energy u Low fiber u Low in complex carbohydrates u Erratic eating patterns Lack of Physical activity

21 Considerations u Clinical Status u Functional Status u Psychological Status

22 Considerations u Cognitive dysfunction u Depression u Hearing and vision loss u Living situation u Economic status u Medications - polypharmacy

23 Cognitive Impairment u Psychomotor function u Global cognition u Semantic memory u Episodic memory u Executive dysfunction à frontal lobe

24 Depression u May go unrecognized u Signs of depression u Poor glycemic control u Insomnia u Hypersomnia u Changes in weight by > 5% with the previous month u Crying spells

25 Screening for Depression u Validated screening tools u Patient Health Questionaire-2 (PHQ-2) u Over the past two weeks, have you often been bothered by: 1. Little interest or pleasure in doing things? 2. Felt down, depressed or hopeless?

26 PHQ-2 u One positive answer indicates a positive screen u If this occurs: u Use a more detailed screening tool u Refer the patient to his/her PCP for follow-up u Refer to a mental health professional u Comprehensive care management

27 Functioning in Older Adults with Diabetes Large community based case control study u Functioning in older adults with diabetes u Reduction in in physical function and health status u More likely to use a mobility aid u More likely to be dependent on caregivers u Sinclair, A., Conroy, S., & Bayer, A. (2008). Impact of diabetes on physical function in older people. Diabetes Care, 31((2)),

28 Increased Risk for Falls u Lower limb dysfunction u Cardiovascular disease u Polypharmacy u Impaired balance

29 Polypharmacy u The use of six or more prescription drugs u Associated with an increased risk of falls

30 Pharmacokinetics in older adults u Decreased GI motility u May affect the rate of drug absorption u Altered renal function u Decreased elimination of renally excreted drugs u Reduced serum albumin u Decreased protein binding

31 Pharmacokinetics in older adults (cont d) Decreased phase I hepatic metabolism Potential accumulation of drugs metabolized by oxidation, reduction, hydrolysis Increased ratio of body fat to lean mass Increased volume of distribution of fat-soluble drugs Decreased total body water Decreased volume of distribution of water-soluble drugs

32 Polypharmacy u Older adults consume more OTC medications than younger adults u Increased risk of drug interactions u Costs are substantial

33 Medication Principles for Older Adults u Start with a low dose titrate slowly u Consider that drugs will have longer half-lives u Avoid rapid dose escalations to avoid ADR u Use the fewest number of drugs possible u Presentation of drug toxicity may be atypical u May manifest as CNS changes u Review medication and diseases when adding new drugs to avoid ADRs

34 Hypoglycemia u More frequent and severe in older adults u Higher risk due to pharmacokinetics u Outcomes u Falls u Fractures u Hospitalizations u Worsening of other conditions

35 Factors contributing to hypoglycemia in Older Adults u Decreased renal clearance u Polypharmacy u Drug to drug interactions u Coexisting comorbidities

36 Association with Hypoglycemia u Cognitive Function u Hypoglycemia unawareness u Prolonged hypoglycemia-induced reaction time u Lower health-related quality of life

37 Hypoglycemic Symptoms Warning symptoms u Younger adults u Tremors, palpitations, sweating, confusion u Older Adults u Confusion, delirium, weakness, dizziness and falls u Patients and caregivers need to be educated about symptoms of hypoglycemia

38 Exercise and Older Adults with Diabetes u Diabetes associated with lower skeletal muscle strength u Benefits of exercise u Muscle strength u Gait u Balance

39 Benefits of Exercise (cont d) u Decreased risk of falls u Improves self-reported health and well being u Low intensity exercise has positive benefits u Resistance training improves glycemic control

40 Diet u Challenges u Life long eating patterns u Depend on others for food shopping and preparation u Inconsistent appetite

41 Dietary Concerns u Decreased food intake and weight loss u Higher body weight associated with lower mortality in patients > 65 compared with younger patients with T2DM

42 Medication Management of Diabetes in Older Adults Metformin à first-line therapy u Low risk of hypoglycemia u Limiting factors u Renal insufficiency u GI side effects u Weight loss

43 Insulin Secretagogues u Longer-acting insulin secretagogues u Sulfonylureas à increased risk of hypoglycemia u Shorter-acting secretagogues u Repaglinide u Nateglinide u Taken just before the meal u May be skipped of added based on meal patterns

44 Incretin-mimetic Agents u DPP-4 inhibitors u Januvia u Onglyza u Tradjenta u Well tolerated u Does not cause weight loss u May be used for patients with renal insufficiency u Less efficacy than other agents

45 Incretin-mimetic Agents u GLP-1 analogs u Causes weight loss u Injectable

46 Insulin u May improve glycemic control u Increases the risk of hypoglycemia u Consider ability to self-administer and/or caregiver resources u Monitoring of blood glucose/smbg u Insulin Pens

47 Education Strategies u The capacity to learn is intact throughout the life cycle u Accommodate u Hearing changes u Visual changes u Cognitive status

48 Education Strategies u Assess older adults for comprehension and memory u Equipment u SMBG u Larger display screens u Audible beeping prompts u Reduced sample size u Easy to grip bodies

49 Equipment u Insulin administration u Insulin pens u Easier to read u Audible clicks u Emphasize the need to push hard enough to administer the dose of insulin u Assess ability to screw the pen needle on and off

50 Other Considerations u Financial concerns u Insurance issues u Transportation

51 Institutional Settings u Assure u Monitoring u Appropriate diet u Prevent and act on acute hyperglycemia and hyperglycemia u Medications u Insulin given correctly and at the right times u Medication interactions u Skin and foot care are part of the daily care regimen

52 Questions?