Special Considerations for Older Adults with Type 2 Diabetes

Transcription

1 Special Considerations for Older Adults with Type 2 Diabetes Supported by Novo Nordisk Inc. This program has been accredited by AADE for pharmacists, nurses, and dietitians. Special Considerations for Older Adults with Type 2 Diabetes is supported by Novo Nordisk Inc. This program has been accredited by the American Association of Diabetes Educators (AADE) for pharmacists, nurses, and dietitians. This program addresses the following aspects of type 2 diabetes in the older adult: epidemiology, pathophysiology of diabetes, treatment options, monitoring, complications, and education. 1

2 Barbara McCloskey, PharmD, BCPS, CDE Diabetes Education Coordinator Baylor Health Care System Irving, TX The following program is a taped presentation by Barbara McCloskey. Ms. McCloskey graduated from the University of Pittsburgh in 1987 with a Bachelor of Science in Pharmacy and she received her PharmD degree from the Medical College of Virginia in Since that time she has been involved in diabetes education in various health care settings. Currently she is the Diabetes Education Coordinator for the Baylor Health Care System Diabetes Services located in north Texas. She oversees the ADA recognition and data management for 12 outpatient diabetes centers. Ms. McCloskey served on the National Certification Board for Diabetes Educators (NCBDE) from and was Chair for the year. She is currently on the Examination Review Committee for NCBDE. In she served as a member of the AADE s Nominating Committee and in 2004 served on the Professional Development, Education, and Resources Committee. Locally she serves on the Program Planning Committee for the North Texas Diabetes Educators. 2

3 Why Focus on Older Adults? Older adults are at greatest risk for diabetes and the development of chronic complications Life expectancies for older adults continue to increase, making the prevention or delay of complications more important in this age group As with younger patients, older adults stand to benefit from improved glycemic control For the purpose of this presentation, we have defined older adults as people who are 65 years or older. I am not going to use terms such as young-old, middle-old, and old-old because the age ranges for these groups vary among different reports. The population of older adults is clearly heterogeneous, and many of the important differences among individuals will not be defined or categorized simply on the basis of their chronological age. What is important to learn about diabetes in older adults? First, older adults are at greatest risk for diabetes and the development of chronic complications Life expectancies for older adults continue to increase, making the prevention or delay of complications more important in this age group As with younger patients, older adults stand to benefit from improved glycemic control 3

4 Health and the Aging Process Individuals of the same chronological age vary considerably in health and functional health status Prevalence of illness and functional impairment rise with age Not all health deficits are equally important Overall health status as well as chronological age should be considered in the management of diabetes We know that describing a person by their age does not necessarily tell us how healthy or unhealthy they are. We can all visualize a 75-year-old person who looks and functions like a 55-year old and, on the other hand, the 50 year old who appears to be much older than his/her stated age. So we know that individuals of the same chronological age vary considerably in health and functional health status, that the prevalence of illness and functional impairment rise with age, and that not all health deficits are equally important. For example, the diagnosis of heart disease would be considered much more serious than the diagnosis of psoriasis. The overall health status as well as the chronological age of a person need to be considered in managing a person with diabetes. 4

5 Objectives At the end of this program, participants should be able to: Discuss the increased prevalence and risk factors for diabetes among older adults Identify three factors that can make diagnosis and treatment of diabetes more difficult in older adults Describe three pharmacologic therapies used in older adults with diabetes List five health concerns that are associated with diabetes and are common among older adults By the end of this program, you should be able to: Discuss the increased prevalence and risk factors for diabetes among older adults Identify three factors that can make diagnosis and treatment of diabetes more difficult in older adults Describe three pharmacologic therapies used in older adults with diabetes List five health concerns that are associated with diabetes and are common among older adults 5

6 Prevalence 18.2 million Americans (6.3%) have diabetes 13 million people diagnosed 5.2 million people undiagnosed Increases with age 6 th leading cause of death among US adults 65 years and older The prevalence of diabetes in the United States is currently estimated to be 18.2 million people or 6.3% of the total population. 13 million people have already been diagnosed with diabetes and 5.2 million people have not yet been diagnosed The prevalence of diabetes does increase with age. Diabetes ranks as the 6 th leading cause of death among US adults 65 years and older. 6

7 Diabetes and the Older Adult 33 to 35 million (of 288 million) Americans are 65 years of age ~6 to 7 million have diabetes ~17 million have 2 or more chronic conditions ~12 million report limited activities due to chronic conditions 71 million will be 65 years of age by 2030, racial and ethnic diversity There are 33 to 35 million Americans who are 65 years or older and about 6 to 7 million of them have diabetes. About 17 million people have 2 or more chronic conditions and about 12 million, who live at home, report limited activities due to chronic conditions. It is projected that the number of adults 65 years and older will increase to 71 million by 2030, with an increase in both racial and ethnic diversity. Based on this information, it is probably safe to say that we will be seeing more and more cases of diabetes in this population in the future. 7

8 Diabetes and the Older Adult Rate (per 100) with diabetes Black male Black female Hispanic male Hispanic female Age (years) White female Black male Black female Hispanic male Hispanic femal Adapted from CDC s Diabetes Surveillance System 2002 As shown in this chart, the incidence of type 2 diabetes begins to increase as the population reaches the mid-forties, and increases dramatically after 65 years of age. You can also see that the African American and Hispanic older adults have a higher rate of diabetes than the Caucasian older adults. 8

9 Risk Factors for Type 2 Diabetes Advancing age Overweight (body mass index [BMI] 25kg/m 2-30kg/m 2 ) Obesity (BMI >30kg/m 2 ) Physical inactivity Ethnicity Family history (first-degree relative) The risk factors for developing type 2 diabetes include: Aging Being overweight, which is defined as a BMI of 25 to 30, and being obese, which is defined as a BMI of greater than 30 Physical inactivity Ethnicity- Native American, African American, and Hispanic Americans have a higher risk of developing type 2 diabetes compared with Caucasians. Having a first-degree relative with diabetes 9

10 Metabolic Syndrome Clinical features (any 3 of the following needed for diagnosis): Impaired glucose tolerance (IGT) or insulin resistance Abdominal obesity Dyslipidemia Low high-density lipoprotein (HDL) cholesterol level Hypertension Prevalence increases with age Metabolic syndrome (sometimes called syndrome X, insulin-resistance syndrome, or dysmetabolic syndrome) has been associated with an increased risk of both cardiovascular disease (CVD) and the development of diabetes. According to the National Cholesterol Education Program, a patient needs to have at least 3 clinical features to be diagnosed with metabolic syndrome. These include: Impaired glucose tolerance (IGT) or insulin resistance Abdominal obesity Dyslipidemia Low levels of HDL cholesterol Hypertension Components of metabolic syndrome may increase vascular aging, leading to arterial stiffening and thickening, which may, in turn, increase the risk of CVD and stroke. The prevalence of metabolic syndrome increases with age to approximately 40% in those over 60 years old. 10

11 Obesity and Older Adults Aging is associated with: body fat lean body mass Weight gain is associated with: Lifestyle changes Endocrine changes Increased visceral fat upper body obesity waist circumference waist-to-hip ratio Aging is also associated with increased body fat and decreased lean body mass. Among US adults over the age of 65, about 36% are overweight and about 21% are obese. Lifestyle changes in older adults often involve a decrease in physical activity with no change in food intake, which leads to weight gain. Weight gain is also associated with endocrine changes in both males and females. Increased visceral fat, which is often characterized by increased waist circumference, is a common change associated with aging. 11

12 Obesity and Glucose Tolerance Visceral fat Skeletal muscle insulin sensitivity glucose uptake Liver insulin sensitivity glucose production Increased visceral fat is associated with: Decreased insulin sensitivity in skeletal muscle tissue, commonly referred to as insulin resistance Decreased glucose uptake because of impaired insulin action, and Decreased insulin sensitivity in the liver. This lack of sensitivity can result in increased glucose production. These metabolic alterations result in an imbalance in the glucose homeostasis mechanism. As a result of these changes, the beta cells of the pancreas produce more insulin as blood glucose levels rise, but the cells can wear out in time because of increased demand. Type 2 diabetes develops when the insulin production of the pancreas can no longer meet these metabolic demands. 12

13 Checkpoint: Test Your Knowledge So Far The prevalence of type 2 diabetes: (a) Does not change with respect to age (b) Increases with advancing age (c) Decreases with advancing age Now it s time for a knowledge check. The prevalence of type 2 diabetes: (a) Does not change with respect to age (b) Increases with advancing age (c) Decreases with advancing age 13

14 The answer is b. The prevalence of type 2 diabetes increases with advancing age. Most of you probably answered b. The prevalence of type 2 diabetes increases with advancing age. 14

15 Undiagnosed Diabetes Is More Common in Older Adults Symptoms often resemble general physiological changes of aging Fatigue, decreased vision, slow wound healing Classic symptoms of diabetes (eg, polydipsia, polyuria) are often absent or not recognized Diagnosis often follows presentation of chronic complications CVD, dyslipidemia, hypertension, impaired renal function Hyperglycemia may be detected incidentally Diabetes is often unrecognized in an older adult because: The symptoms of diabetes are similar to some of the physiological changes associated with aging, such as fatigue, decreased vision, and slow wound healing. Often the classic symptoms of diabetes such as polydipsia and polyuria are not present in patients with type 2 diabetes or symptoms of diabetes are not recognized because they are thought to be due to another disease or a medication the patient is taking. Oftentimes the diagnosis of diabetes is made after one of its complications such as CVD, poor wound healing, or retinopathy are detected. Hyperglycemia may also be detected incidentally by routine labs done at an office visit. Nearly 40% of individuals 60 to 75 years of age may be affected by hyperglycemia. In a study of older adults, 73 years of age and older, dry mouth, increased fatigue during the day, and numbness of the hands were found to be associated with undiagnosed diabetes. 15

16 Diabetes Affects Independence Adults with diabetes, aged >60 years experienced 2X to 3X increased risk of inability to: Walk 400 meters Do housework Prepare meals In a study of women 65 years old, diabetes was found to result in a 42% increased risk of becoming disabled Diabetes Care. 2000;23(9): ; 2002;25(1): Diabetes can affect activities of daily living and impact a person s independence. Older adults with diabetes experienced 2X to 3X increased risk of inability to: Walk 400 meters Do housework Prepare meals In a study of women 65 years or older, diabetes was found to result in a 42% increased risk of becoming disabled. 16

17 Recommendations for Screening Regular screening (at least once every 3 years) is recommended for all adults over 45 years of age. According to the ADA, screening should be more frequent when additional risk factors are present: Overweight (BMI >25 kg/m 2 ) Members of high-risk group Previously identified IGT or IFG Hypertension (blood pressure [BP] >140/90 mm Hg) HDL cholesterol <35 mg/dl Triglycerides >250 mg/dl History of vascular disease or gestational diabetes Polycystic ovary syndrome Screening for diabetes at 3-year intervals has been recommended for all adults over 45 years of age. More frequent screening beginning at a younger age has been recommended by the American Diabetes Association (ADA) when any of the following risk factors are present: Overweight (BMI >25 kg/m 2 ) Members of high-risk group Previously identified IGT or IFG Hypertension (BP >140/90 mm Hg) HDL cholesterol <35 mg/dl Triglycerides >250 mg/dl History of vascular disease History of gestational diabetes Polycystic ovary syndrome 17

18 Treatment Goals for Older Adults Same goals as for younger patients: Control hyperglycemia Minimize, delay, prevent long-term complications Avoid hypoglycemia Achieving individual treatment targets is as important for older adults as it is for younger people. Additional considerations for older adults: Assess life expectancy and quality Assess physical, mental capability Some controversy exists regarding the treatment goals for diabetes in the older individual. As in younger individuals, the primary goals of treatment are to control hyperglycemia, to prevent acute and long-term complications, and to avoid hypoglycemia. Older adults are often more prone to medication-induced hypoglycemia. Use of sulfonylureas and other antidiabetic agents increase the risk of hypoglycemia, as do other commonly prescribed medications such as angiotensin-converting enzyme inhibitors and beta-blockers. Severe hypoglycemia is of particular concern for older adults, who are at increased risk for injurious falls. Aggressive therapy, therefore, has traditionally not been used. With increased life expectancies however, men and women at 65 years of age can potentially live another 15 to 25 years. Therefore, the factors to be considered include: Presence and severity of long-term complications Quality of life Presence of other medical disorders Ability to follow an intensive treatment program 18

19 Setting Individual Targets and Goals Treatment, goals, and targets for the older adult should be individualized based on patient s condition and desires. In healthy older adults, reducing A1C to ADA or AACE recommended levels may be reasonable. American Geriatric Society suggests considering more relaxed A1C for older adults when: Their condition is very frail Life expectancy is <5 years Risks of an aggressive regimen of glycemic control will outweigh the benefits The ADA recommends maintaining A1C levels below 7.0% whereas the AACE recommends maintaining A1C levels below 6.5%. No specific values have been recommended for older adults who are in frail condition; however, it has been suggested by the California Healthcare Foundation and the American Geriatric Society (AGS) that an A1C target below 8% might be reasonable in some cases where the risks of an aggressive treatment regimen would likely outweigh the benefits of improved glycemic control. 19

20 Factors Affecting Glycemic Control in Older Adults Comorbid conditions Economics Social changes Difficulty preparing or eating food Polypharmacy Altered senses Altered circulation Altered renal, hepatic function Decreased mobility or physical activity Various factors must be considered in the older adult with diabetes, such as: Older individuals often have more than one chronic disease and take multiple medications, which they may be getting from more than one pharmacy. The potential for drug interactions should always be evaluated. Many older individuals live on a fixed income and do not have private health insurance to supplement Medicare/Medicaid. The cost of therapy, particularly oral medications, can be difficult for some older adults. Changes in the environment, such as moving from their home to a relative s home or to assisted living, or finding themselves unable to prepare food properly in their own home, must also be considered. Social changes may lead to isolation, less ability to care for themselves, and less access to medical care. Many older individuals need the support of family, in-home or visiting health practitioners, or long-term care to manage their diabetes. Circulation, renal, and hepatic function usually decline with age, putting the elderly at risk for accumulation of certain medications and increased toxicity. Physical and mental impairment, because of age or physiological changes, can result in decreased mobility or physical activity. Elderly adults with reduced dexterity and visual acuity may have difficulty opening medication bottles, measuring insulin doses, or following label directions. 20

21 Adherence to Therapy Adherence to therapy is often poor among all adults. A study of adults 65 years old in managed care found: Increased adherence by patients was associated with reduced healthcare costs. Insulin use was associated with reduced adherence to drug treatment. Clin Ther. 2003;25(11): Adherence to medications, both oral medications and insulin, is often poor among adults. An observational study of adults 65 or older in a managed care setting found that increased adherence by patients was associated with reduced healthcare costs. However, regimens involving insulin injection were associated with reduced adherence to drug treatment. Limitations of this study did, however, preclude causal determination and prevented assessment of variability associated with insulin regimens. 21

22 Monitoring Self-monitoring of blood glucose (SMBG) Routine medical visits Screening for depression and cognitive impairment A1C Lipids, cholesterol, and blood pressure Dilated eye exam Foot exam Microalbumin Blood or urine ketone testing Self-monitoring of blood glucose (SMBG) is essential to assess blood glucose control and to minimize the risk of hypoglycemia. Individual instruction in the use of glucose meters may be needed, and assessment of dexterity and ability to perform this skill should be done. Regularly scheduled medical visits are especially important for managing diabetes in the older adult. These visits should include: Screening for depression and assessment for cognitive impairment A1C testing, at least quarterly, for assessment of overall diabetes management Management of cardiovascular risk factors such as lipid levels and blood pressure Yearly dilated eye examination A thorough annual foot examination to assess protective sensation, foot structure, vascular status, and skin integrity Yearly microalbumin testing Urine ketone testing (usually limited to patients with type 1 diabetes and lean patients with type 2 diabetes; in these patients ketone testing should be performed during sick days and when blood glucose levels are greater than 240 mg/dl). 22

23 Checkpoint: Test Your Knowledge So Far Adults over the age of 45 years should be screened for diabetes: (a) at least once every 3 years (b) at least once every 5 years (c) less often as they get older Adults over the age of 45 years should be screened for diabetes: (a) at least once every 3 years (b) at least once every 5 years (c) less often as they get older 23

24 The answer is a. Adults over the age of 45 years should be screened for diabetes at least once every 3 years. The answer is a. Adults over the age of 45 years should be screened for diabetes at least once every 3 years. 24

25 Management of Diabetes in the Older Adult Medical nutrition therapy Regular physical activity Pharmacological treatment Monitoring blood glucose Education The basic principles of diabetes management, which are the same for all patients regardless of age, include: Medical nutrition therapy Regular physical activity Pharmacological treatment Monitoring blood glucose Education Some special considerations however, do apply to older adults. 25

26 Medical Nutrition Therapy Assess current dietary and physical activity patterns Identify food intolerances, allergies, mechanical difficulties that may impact a nutrition care plan Identify lifestyle or social factors that may interfere with compliance to prescribed meal plan Meal plan prescription Optimally, all older adults with diabetes should receive medical nutrition therapy from a registered dietitian. Medical nutrition therapy for people with diabetes is covered by Medicare as well as many insurance plans. Medical nutrition therapy consists of: Assessing the patient s nutritional status, including identifying food intolerances, allergies, or mechanical difficulties that may impact his or her nutritional care plan such as dentition Identifying lifestyle or social factors that may interfere with compliance to the prescribed meal plan and Developing a meal plan that is individualized to the patient s needs. 26

27 Benefits of Regular Physical Activity Occasional moderate physical activity may reduce all-cause mortality among adults aged 65 years and older. glucose tolerance insulin sensitivity blood pressure joint flexibility sense of well-being circulation lean body mass + muscle This slide lists benefits that may result from regular physical activity, which should be encouraged in older adults following consultation with their healthcare provider. Improved glucose tolerance Increased insulin sensitivity Reduced blood pressure Improved joint flexibility Improved sense of well-being Improvements in circulation Increased lean body mass and muscle 27

28 Regular Physical Activity: Precautions for the Older Adult Physical examination Activity selection Hydration, source of glucose replacement Monitoring of blood glucose levels Exercise-induced hypoglycemia and post-exercise hypoglycemia Medical identification (ID) Proper recommendations and supervision of exercise are critical for older adults. A physical examination should be conducted and the patient evaluated for potential risk factors, such as the presence of microvascular disease and loss of sensation in the feet. An individual s preferences for activities should be discussed and functional ability to perform various types of exercise should be assessed. For example, patients with retinopathy should be counseled not to engage in weight lifting. During exercise, it is important that the patient be adequately hydrated. This is of special concern in older adults, who are at increased risk of dehydration. If appropriate, immediate sources of glucose replacement should be discussed. Individuals should be advised of the importance of SMBG and be instructed as to appropriate actions based on their blood glucose results. Monitoring before and after exercise is recommended. Exercise-induced hypoglycemia and late onset post-exercise hypoglycemia, occurring 4 or more hours following activity, are important concerns for older adults. All individuals with diabetes should wear easily visible medical identification. 28

29 Pharmacological Therapy Oral antidiabetic drugs (OADs) Insulin and insulin analogs Combination therapy Because diabetes is a progressive disease, most patients will require medication when medical nutrition therapy and regular physical activity fail to keep blood glucose levels within the target range. Patients may start with one oral medication but many physicians are currently using combination therapy to address the dual nature of type 2 diabetes. 29

30 Specific Considerations for Selecting Medications for Older Adults How is the drug metabolized? What other medications are being prescribed? What is known about the drug s use in older adults? What is the level of cognitive ability? Selecting the appropriate medication for an older adult should take into account the following: Since hepatic and renal function decrease with age, how a drug is metabolized and eliminated is an important consideration. Due to the potential for drug interactions, other medications the patient is taking must also be evaluated. Because older adults are at increased risk for adverse drug reactions compared with younger patients, it is important to know about studies done with the drug in the older population. Finally, it is important to assess what the patient is able to do to adhere to a medication regimen. The most effective medication regimen will not work if the patient cannot follow it. Simplified regimens along with pillboxes or timers can be used to assist with medication adherence. 30

31 Some Medications Affect Blood Glucose Levels Lower blood glucose Alcohol Beta-blockers Salicylates Raise blood glucose Glucocorticoids Sympathomimetics Diazoxide Diuretics Phenytoin sodium Atypical (2 nd generation) antipsychotic agents Alcohol It is important to be aware that some medications can lower or raise blood glucose levels. Drugs that have been associated with hypoglycemia include: Alcohol, which impairs gluconeogenesis and enhances the response to insulin Nonspecific beta-blockers such as propranolol inhibit gluconeogenesis and glycogenolysis and can mask the signs of hypoglycemia such as tachycardia, tremor, and anxiety High-dose salicylates may alter the pharmacokinetics of sulfonylureas, increase utilization of glucose by peripheral tissues, cause reduction of gluconeogenesis, and may potentiate insulin secretion. Drugs that can cause hyperglycemia include: Glucocorticoids, such as prednisone, which increase gluconeogenesis and depress insulin action Sympathomimetics, which increase glycogenolysis and gluconeogenesis Diazoxide inhibits the secretion of insulin Diuretics can inhibit insulin secretion indirectly, by depletion of potassium Phenytoin can also inhibit insulin secretion Recently, second-generation or atypical antipsychotic agents have been associated with the development of diabetes Chronic use of alcohol can raise blood glucose levels 31

32 Types of OADs Insulin secretagogues Stimulate insulin release Insulin sensitizers Improve response to insulin Alpha-glucosidase inhibitors Delay carbohydrate digestion Combination formulations Insulin sensitizer + insulin secretagogue Combination of two sensitizers Currently there are four classes of oral antidiabetes drugs. Insulin secretagogues that stimulate insulin release from pancreatic beta cells Insulin sensitizers that improve response to insulin, resulting in improved glucose utilization at the cellular level (two different types) Alpha-glucosidase inhibitors that delay carbohydrate digestion by enzymatic inhibition Combinations of some of these medications are now available that can help to simplify medication regimens by decreasing the number of pills per day a patient takes. 32

33 Secretagogues Sulfonylureas Monotherapy or combination therapy Most common side effect is hypoglycemia Contraindicated with renal or hepatic insufficiency Chlorpropamide is not recommended for use in older adults Some generics are available Sulfonylureas are the class of medications that have been on the market the longest. Most of the sulfonylureas are indicated for both monotherapy and combination therapy. Because of the continuous action of sulfonylureas on the beta cells, the most common side effect is hypoglycemia. Severe hypoglycemia, which may be life threatening, has been identified as a common cause of hospitalization in people aged 80 years and above with type 2 diabetes. Hypoglycemia can be of special concern for the older adult who may have inconsistent eating patterns. Patients should be instructed on the signs, symptoms, and treatment of hypoglycemia. Sulfonylureas are metabolized in the liver and excreted through the kidney. They should be used with caution in older adults and may be contraindicated when impaired renal or hepatic function is present. Chlorpropamide should not be used in older adults due to its long half-life. Other side effects of sulfonylureas include headache, nausea/diarrhea, rashes, and a bitter metallic taste. One advantage of using sulfonylurea drugs is that many of them are available generically making them relatively inexpensive. 33

34 Secretagogues Nateglinide and Repaglinide Fast-acting, rapid absorption and onset Nateglinide may be used with caution in patients with impaired renal or hepatic function Repaglinide should be used with caution in patients with moderate to severe liver disease The newer secretagogues are nateglinide and repaglinide. They are fast-acting and have rapid absorption and onset. Because they work on the pancreas they can also cause hypoglycemia; however, because they are short-acting, it is less likely to happen compared with the sulfonylureas. These medications may be useful in patients who do not have regular eating schedules as they can take the medication when they eat. Nateglinide may be used with caution in patients with impaired renal or hepatic function. Repaglinide should be used with caution in patients with moderate to severe liver disease. 34

35 Sensitizers Biguanides (metformin) May be used as part of combination therapy Risk of lactic acidosis Should not be used with renal or hepatic insufficiency, or with congestive heart failure Can lower cholesterol and triglycerides Not associated with weight gain Thiazolidinediones (rosiglitazone and pioglitazone) Combination therapy available Should not be used with hepatic problems or with heart failure The two classes of insulin sensitizers include biguanides and thiazolidinediones. Metformin, the only biguanide currently available, is commonly used as part of combination therapies. The biggest concern with this drug is the risk of lactic acidosis. It should not be used in patients with renal or hepatic insufficiency, alcoholics, or those with congestive heart failure. Patients using metformin should have his/her creatinine levels monitored at least annually as well as with every dose increase. The benefits of using metformin are that it can lower cholesterol and triglycerides and it is not associated with weight gain. Rosiglitazone and pioglitazone are the two available thiazolidinediones. Rosiglitazone is available in combination therapy with metformin. Neither of these drugs should be used in patients with hepatic problems or heart failure. 35

36 Alpha-glucosidase inhibitors (acarbose and miglitol) Not associated with weight gain Should not use with intestinal disorders Not associated with hypoglycemia when used alone; however, may increase the risk arising from concomitant medications Need to use a monosaccharide, such as glucose, to treat hypoglycemia due to inhibition of carbohydrate catabolism A class of medications not highly utilized are the alpha-glucosidase inhibitors, which include acarbose and miglitol. On the plus side, these medications are not associated with weight gain. On the negative side, they should not be used in patients with intestinal disorders as they cause gastrointestinal side effects, one of the reasons for their low usage. They don t cause hypoglycemia when used alone; however, if they are used with insulin or an insulin secretagogue they may increase the risk of hypoglycemia from these medications. If hypoglycemia does occur the patient needs to use a monosaccharide, such as glucose, to treat his/her hypoglycemia because of the drug s mechanism of action. 36

37 Checkpoint: Test Your Knowledge So Far Which of the following should be considered when choosing medications for an older adult: (a) Cognitive ability (b) How the drug is metabolized (c) Concurrent medications (d) All of the above Which of the following should be considered when choosing medications for an older adult: (a) Cognitive ability (b) How the drug is metabolized (c) Concurrent medications (d) All of the above 37

38 The answer is d. Cognitive ability, how the drug is metabolized, and concurrent medications should be considered when choosing medications for an older adult. The answer is d. Cognitive ability, how the drug is metabolized, and concurrent medications should all be considered when choosing medications for an older adult. 38

39 When to Consider Insulin Therapy? First-line therapy in cases with: Severe hyperglycemia Ketonuria OAD intolerance Before failure to maintain glycemic targets using OADs During acute illness, surgery, hospitalization Insulin and insulin analogs are highly effective glucose-lowering agents and should be considered first-line therapy in patients with severe hyperglycemia, ketonuria, and in patients with intolerance or contraindications to OAD medications. Some prescribers will use insulin as initial therapy to achieve glycemic control, changing to an oral agent, if appropriate. As discussed earlier, because type 2 diabetes is a progressive disease, insulin is usually needed to maintain adequate glycemic control. Ideally, insulin should be initiated before the patient fails OADs; however, because of the resistance to using insulin, that is usually not the case. Insulin is also commonly used during acute illness, surgery, and hospitalization. A very valid concern with the use of insulin is the risk for hypoglycemia and weight gain; however, these concerns should not preclude its use. Patients need to be educated on the importance of following their exercise and meal plans as well as the signs, symptoms, prevention, and treatment of hypoglycemia. 39

40 Physiologic Serum Insulin Profile 75 Breakfast Lunch Dinner Plasma Insulin ( µu/ml) :00 8:00 12:00 16:00 20:00 24:00 4:00 Time 8:00 The graph depicts the physiologic serum insulin secretion profile of a nondiabetic individual who eats three meals per day. The insulin plasma concentrations are shown in yellow. As you can see, following the ingestion of a meal, there is a rapid burst of insulin released from the pancreas. The secretion of insulin in response to a glucose load has 2 phases. The first phase occurs within 10 minutes of receiving a glucose load and is the secretion of stored insulin. This response is often tested using an intravenous (IV) glucose tolerance test (IVGTT). Loss of first-phase insulin secretion in response to an IVGTT is the earliest detectable abnormality in type 2 diabetes. The second phase of insulin secretion begins about 20 minutes after a glucose load and represents newly synthesized insulin in the beta cells. The goal of insulin therapy is to mimic this profile as closely as possible, taking into account individual requirements. 40

41 Types of Insulin and Insulin Analogs Short-acting insulin Regular human insulin (Humulin R, Novolin R) Rapid-acting acting insulin analogs Insulin lispro (Humalog ) Insulin aspart (NovoLog ) Insulin glulisine (Apidra ) There are several types of insulin on the market to assist with designing insulin regimens to meet the needs of a variety of patients. Short-acting insulin and rapid-acting insulin analogs are used in multiple daily injection (MDI) regimens and in intensive insulin therapy to mimic normal insulin action after eating. These formulations are also used in insulin pumps. Regular insulin is considered a short-acting insulin and is available as Humulin R and Novolin R The rapid-acting insulin analogs include: Humalog - insulin lispro NovoLog - insulin aspart and Apidra - insulin glulisine, which has been approved by the US Food and Drug Administration, but is not yet available in the United States as of March

42 Types of Insulin and Insulin Analogs Intermediate-acting acting insulin Lente human insulin NPH human insulin Long-acting insulin Ultralente human insulin Long-acting insulin analog Insulin glargine (Lantus ) The intermediate- and long-acting insulins are used to mimic the basal secretion of insulin. There are two intermediate-acting insulins on the market Lente insulin and NPH insulin. Ultralente insulin is the only long-acting human insulin available and insulin glargine (Lantus) is the long-acting insulin analog currently available. 42

43 Types of Insulin and Insulin Analogs Premixed insulin Humulin 70/30 Novolin 70/30 Humulin 50/50 Premixed insulin analogs Humalog Mix75/25 NovoLog Mix 70/30 Premixed formulations combine short-acting insulin or a rapid-acting insulin with an intermediate-acting insulin. Premixed human insulins include: Humulin 70/30 (70% NPH human insulin isophane suspension, 30% Regular human insulin injection [rdna origin]) Novolin 70/30 (70% NPH human insulin isophane suspension, 30% Regular human insulin injection [rdna origin]) Humulin 50/50 (50% NPH human insulin isophane suspension, 50% Regular human insulin injection [rdna origin]) Premixed insulin analogs include: Humalog Mix75/25 (75% insulin lispro protamine suspension and 25% insulin lispro injection [rdna origin]) NovoLog Mix 70/30 (70% insulin aspart [rdna origin] protamine suspension and 30% insulin aspart [rdna origin] injection) 43

44 Special Considerations for Initiation of Insulin Therapy in Older Adults Mental status Ability to learn and recall dosing regimen Ability to mix different insulin formulations and adjust dosage Resistance to injections Manual dexterity Ability to use insulin delivery system Ability to self-inject Visual acuity Ability to dose accurately Quality of life When designing insulin regimens for older adults, the following considerations should be assessed: Older adults should be evaluated for their ability to learn and recall their dosing regimen, and to perform blood glucose monitoring. Manual dexterity is an important consideration, especially with regard to the ability to use an insulin delivery system as well as self-administer injections. Reduced visual acuity may affect the individual s ability to dose insulin accurately. Newer insulin delivery systems are available to make taking insulin easier. Some require less manual dexterity and accommodate reduced visual acuity, compared with syringe and vial. The presence of complications and life expectancy should be considered when deciding on the use of insulin therapy in older adults. 44

45 Insulin Delivery Systems Vial and syringe Prefilled disposable insulin doser Prefilled disposable insulin pens Durable insulin pens and dosers Combination insulin doser and blood glucose meter External insulin pumps continuous subcutaneous insulin infusion (CSII) A number of delivery systems are available as alternatives to vial and syringe to meet the various needs of insulin-using individuals. These include insulin pens and dosers with cartridges, prefilled disposable insulin pens or dosers, and jet injectors. Some of these systems may be helpful to older adults because of easy and accurate dosing; large, easy-to-see numbers; and easier handling when dexterity problems are present. A study, reporting on 112 elderly patients with a mean age of 69.4 years responding to a questionnaire, demonstrated that a disposable insulin doser was preferred over vial and syringe in ease-of-use assessments. If you want to learn more about these devices, detailed descriptions may be found on manufacturers Web sites or from the ADA Resource Guide. 45

46 Insulin Pens and Dosers Humalog Mix75/25 Pen NovoLog Mix 70/30 FlexPen Novolin InnoLet doser Examples of some insulin delivery systems that are currently available include: Novolin InnoLet doser, which is shown on the bottom of this slide Two pen devices are shown here: the Humalog Mix75/25 Pen and the NovoLog Mix 70/30 FlexPen InDuo is not shown on the slide; however, it is a combination insulin doser and blood glucose monitor in one device 46

47 Concerns for Older Adults with Diabetes Depression Polypharmacy Cognitive impairment Urinary incontinence Neuropathic pain Injurious falls The American Geriatric Society guidelines identify the following conditions as concerns for older adults with diabetes: Depression Polypharmacy Cognitive impairment Urinary incontinence Neuropathic pain Injurious falls diabetes is a risk factor for orthostatic hypotension, which may cause up to 16% of all falls, and may contribute to as many as 26%; and, as with diabetes, the prevalence of orthostatic hypotension increases with advancing age 47

48 Hyperosmolar Hyperglycemic State (HHS) Most common in elderly with undiagnosed or untreated type 2 diabetes Precipitating factors Infection is the most common cause Drugs, acute/chronic diseases that blood glucose Dehydration Most common cause of diabetic coma in older patients Life threatening Another concern in older adults is hyperosmolar hyperglycemic state or HHS. This condition is most commonly the result of a precipitating factor such as infection, but may also be the result of a cardiovascular event such as a myocardial infarction or stroke. Other causes can include drugs or disease states that cause dehydration such as diuretics, diarrhea, and severe burns. Because HHS generally occurs in patients with type 2 diabetes who are capable of some insulin production, ketosis and acidosis are not usually presenting features that differentiate this from diabetic ketoacidosis. Both conditions can be life threatening; therefore, prompt recognition and treatment are vital. 48

49 Symptoms and Treatment of HHS Clinical signs Thirst, coma or confusion, dehydration Blood glucose >600 mg/dl Serum osmolality >320 mosm/kg Ketosis absent or mild Corrective measures Correct precipitating event Rehydrate Treat hyperglycemia with insulin Potassium replacement for electrolyte imbalance The severe hyperglycemic and hyperosmolar state associated with HHS typically leads to profound dehydration and confusion or coma. Common signs and symptoms of HHS include stupor, dehydration, and hypotension. The neurologic signs and symptoms can range from aphasia to seizures or coma. Treatment of HHS should be prompt and include correcting the precipitating event and rehydration with normal saline as dehydration is the primary initial concern. If fluid replacement does not correct the hyperglycemia, then insulin and potassium may be needed. 49

50 Hypoglycemia in the Older Adult Higher risk for medication-induced hypoglycemia due to: Decreased or slowed glucagon response Inadequate hydration/food intake Slowed intestinal absorption Renal insufficiency Reduced awareness of warning cues Polypharmacy Increased risk of morbidity Associated with stroke, myocardial infarction Injuries from falls Older adults who use insulin or take insulin secretagogues are at increased risk for hypoglycemia for a variety of reasons including: Slowed hormonal counterregulation Inadequate or inconsistent hydration and/or food intake Slowed intestinal absorption Renal insufficiency Patients with cognitive impairment may not be able to recognize the signs and symptoms of hypoglycemia. Finally, multiple medications may increase the risk of hypoglycemia due to drug-drug or drug-disease interactions. Even mild recurrent episodes of hypoglycemia are likely to negatively affect the quality of life in older adults. Decreased coordination is not uncommon among older adults, and symptoms resembling cognitive impairment or senile dementia may make the recognition of hypoglycemia more difficult. Hypoglycemia has been associated with stroke or myocardial infarction, although controversy exists as to its correlation with new cardiovascular events. Older adults are at an increased risk of injuries from falls or stumbles as a result of hypoglycemia. 50

51 Hypoglycemia Treatment Fast-acting carbohydrate Check blood glucose Follow with meal or snack If not alert: glucagon, emergency measures Treatment of hypoglycemia depends on the blood glucose level and patient s symptoms. When educating a patient on treating hypoglycemia the basic steps are to treat with a fast-acting carbohydrate such as glucose tablets, check blood glucose if possible, and then follow with a meal or snack, if necessary. If a patient s blood glucose level is less than 70 mg/dl but greater than 50 mg/dl, the treatment is usually 10 to 15 grams of a carbohydrate-containing food or beverage. If blood glucose levels are less than 50 mg/dl, then 20 to 30 grams of carbohydrate may be needed. The patient should check their blood glucose level minutes after initiating treatment. If their blood glucose level remains low, repeat the treatment even if symptoms have disappeared. Patients should be advised that hypoglycemia may reappear if a meal or carbohydrate/protein containing snack is not eaten within 1-2 hours of the event. Patients should be educated that beverages and foods high in fat content take longer to raise blood glucose levels and therefore should not be used. If patients are not alert, uncooperative or unable to swallow, then emergency measures are required. For patients who have experienced severe hypoglycemia, it may be necessary to teach family members or caregivers when and how to inject glucagon. 51

52 Hypoglycemia Prevention Educate loved ones and caregivers Recognizing typical symptoms Understanding that atypical symptoms may occur, especially in the elderly Proper monitoring of blood glucose Eating habits, alcohol-related risks Increase involvement and awareness of entire healthcare team Encourage patient to wear medical ID Ideally hypoglycemia can be avoided through prevention. This is especially important for those older adults who live alone or have limited assistance available. As part of the diabetes team we can educate patients and their families and/or caregivers on the risk of hypoglycemia and how to recognize, avoid, and treat it. With some patients it may be helpful to educate them about hypoglycemia on a regular basis. Asking the patient about occurrences of hypoglycemia, and working with the healthcare team to evaluate the causes may provide opportunities for education and treatment. Be alert to A1C level and understand that normal values may indicate control that is aggressive enough to put an elderly patient at increased risk for hypoglycemia. Encourage patients who are at risk for hypoglycemia to wear medical ID. 52

53 Long-term Diabetes Complications in the Older Adult Macrovascular complications Cardiovascular disease: leading cause of death Coronary artery disease: 2X to 4X greater risk Peripheral vascular disease: >15X risk of amputations; 64% of amputations associated with diabetes occur in patients 65 years of age The long-term macrovascular complications of diabetes are very common. Cardiovascular disease is responsible for more than 80% of deaths in the diabetic population. Coronary artery disease is 2 to 4 times greater in individuals with diabetes than in the general population and the risk for myocardial infarction increases with age. Peripheral vascular disease is another macrovascular complication and those with diabetes have a 15 times higher age-related risk for amputation. An unbelievable 64% of all amputations associated with diabetes occur in patients 65 years of age and older. Controlling hyperglycemia, hypertension, hyperlipidemia; encouraging regular exercise; and frequent visits to their healthcare team can help decrease macrovascular complications. 53

54 Long-term Diabetes Complications in the Older Adult Microvascular complications Retinopathy - eye Nephropathy - kidney Neuropathy - nerves The long-term microvascular complications of diabetes include retinopathy, which is present in 90% of patients who have had diabetes for more than 20 years. Aging can decrease visual acuity; and cataracts and macular degeneration are more common in older adults with diabetes. Patients should be counseled to have an annual dilated eye exam, on the importance of controlling hyperglycemia and blood pressure, and on smoking cessation. Diabetic nephropathy is the most common single cause of end-stage renal disease in the United States and Europe; it develops in 40%-50% of patients who have had type 1 diabetes for more than 20 years; it is less common in those with type 2 diabetes except for certain ethnic groups; and individuals over 60 years of age represent 55% of all cases of end-stage renal disease. Patients should be counseled on the importance of controlling hyperglycemia, blood pressure, testing for microalbuminuria, and smoking cessation. If appropriate, they should be encouraged to moderately reduce sodium intake. Peripheral neuropathy is the most common diabetic complication; it develops in 60%-70% of those with diabetes for more than 10 years; it involves increased large and small nerve fiber damage and patients experience sensory deficits, sexual dysfunction, gastrointestinal, and dental problems. Patients should be counseled to control hyperglycemia and inspect their feet daily. 54

55 Checkpoint: Test Your Knowledge So Far What percentage of amputations associated with diabetes occur in adults 65 years and older? (a) 24% (b) 44% (c) 64% What percentage of amputations associated with diabetes occur in adults 65 years and older? (a) 24% (b) 44% (c) 64% 55

56 The answer is c. Sixty-four percent of amputations associated with diabetes occur in adults 65 years and older. The answer is c. Sixty-four percent of amputations associated with diabetes occur in adults 65 years and older. 56