The older person with co morbidities. Eugene Hughes General Practitioner Isle of Wight

Transcription

1 The older person with co morbidities Eugene Hughes General Practitioner Isle of Wight

2 Eugene Hughes Age 60 BMI 26.5 BP 125/70 Alcohol intake moderate (?) TC 5.6 Regular exercise Non smoker Stress free

3 Eugene Hughes Mother has type 2 diabetes Father died of MI age 51 Grandmother had type 2 diabetes, died age 95 Uncle has type 2 diabetes HbA1c = 50 mmol/mol on 2 occasions, no symptoms

4 What next for me? Lifestyle change? VLC diet? Commence metformin? Commence statin? Commence aspirin?

5 Priorities? Glucose, lipids, BP BP, lipids, glucose Lipids, glucose, BP Glucose, BP, lipids

6 HbA1c target? < mmol/mol < mmol/mol < mmol/mol

7 Would it be different if I was 70? 80? 90?

8 Would it be different if I was Frail, whatever that means? Lacking mental capacity? Recently diagnosed with prostate cancer?

9 Contents What evidence exists for the management of blood pressure, blood glucose and lipids in the elderly population? Can we define frailty? What about end of life care in people with diabetes?

10 Why is it important? Globally, diabetes is being diagnosed in epidemic proportions and whilst the estimated diabetes prevalence for 2013 is 382 million it is expected to affect 592 million people by By 2050, the proportion of older persons (over age 60 as defined by the UN) will have risen from 15% today to 25%. These changes present significant challenges to welfare, pension, and healthcare systems

11 IDF guideline on older people with diabetes It is increasingly important that modern recommendations for managing diabetes are more closely aligned with additional individual characteristics such as; functional status, presence of frailty and dependency, comorbidity profiles, life expectancy.

12 Co morbidity Hypertension Renal disease CV disease Depression Arthritis Sexual dysfunction Cancer

13 Polypharmacy Statins Fibrates NSAIDs Warfarin / NOACs Aspirin Clopidogrel PPIs Antidepressants Antipsychotics Antihypertensives Diuretics Osteoporosis OTC Gabapentin

14 POLYPILL Atorvastatin Ramipril Metformin A2RA Gliptin Ezetimide Diuretic Dispersible aspirin Omeprazole Nicotinic acid

15 Case study 1 Brian, aged 81, T2D Metformin 1000mg bd Gliclazide 80mg bd Lisinopril 20mg od Bendroflumethiazide 2.5mg od Simvastatin 40mg od Paracetamol PRN BP 126/76 TC 4.2 mmol/mol HbA1c 51mmol/mol (6.8%) Widow, lives alone Poor mobility Son does shopping C/o tiredness

16 Brian, 81 Ask Brian what he wants and discuss appropriate goals Ask him to discuss it with his son Is he depressed??stop gliclazide ( hypo risk)?stop bendro ( BP is low) Does he need statin, Lisinopril, metformin?

17 Mabel, 84, in a nursing home CVA Can t speak Bedbound PEG feed BP 110/70 TC 4.2 mmol /L HbA1c 66 mmol/mol (8.2%) Aspirin disp 75mg od Simvastatin oral soln 40mg od Ramipril oral soln 5mg od Omeprazole disp 20mg od Metformin soln 500mg bd Co codamol eff 2 qds Glargine 40 units daily

18 Mabel Try to ascertain Mabel s wishes, along with her family and carers Stop Ramipril ( BP too low) Consider stopping statin, aspirin, insulin, omeprazole?change to soluble paracetamol

19 Guiding principles An holistic, individualized care plan is needed for each older person with diabetes. It is important to adopt a proactive risk identification and minimization approach that includes planning for key transitions in older people such as stopping driving, moving to aged care homes, or supported community care and end of life care. A focus on patient safety, avoiding hospital/emergency department admissions and institutionalization by recognizing the deterioration early and maintaining independence and quality of life to a dignified death.

20 Categories of older people with diabetes (IDF) Functionally independent living independently no impairment of ADL Functionally dependent frail dementia End of life care

21 Frailty definition low grip strength, less than 20% of normal low energy, self reported slowed walking speed, measured over 15 feet low physical activity unintentional weight loss Rockwood, Age and Ageing 2005; 34:

22 The Grim Reaper Walking speed 0.82 m/s

23 Medicines management in older people Medicines are associated with significant risks in older people such as falls, confusion and other cognitive changes, and admission to hospital Older people experience a disproportionate number of medicine related adverse events, even adjusting for age When new symptoms emerge: consider any new symptom as related to a medicine/s until proven otherwise.

24 Medicines management in older people Consider the medicine burden and reduce polypharmacy, the complexity of the dose regimen, and consider stopping medicines where possible and safe (deprescribing). Use the lowest effective dose, increase doses slowly, and monitor the effects including adverse effects, Anticipate difficulties adhering to the medicine regimen and consider whether alternative dose forms are needed (e.g. swallowing difficulties)

25 Quality use of medicines Consider factors that contribute to medicines related adverse outcomes; Polypharmacy Inappropriate prescribing Presence of renal / hepatic impairment Living alone Cognitive impairment Sensory deficits

26 CV risk assessment All people with diabetes aged 60+ years are considered at high cardiovascular risk and application of a risk equation is unnecessary. All people with diabetes aged 60 and over are at increased CVD risk and should be considered for CVD prevention measures. However since many interventions take a number of years to demonstrate benefit, their initiation may not be warranted in those with a limited life expectancy. The Framingham risk score has been validated for people up to 75 years but has been shown to be unreliable in older persons

27 Addressing CV risk Functionally independent Modifiable individual cardiovascular risk factors should be treated as for younger people with diabetes. Functionally dependent The emphasis should be on the identification and management of more easily modifiable risk factors End of life care Specific assessment of cardiovascular risk is usually unnecessary.

28 Glucose control general recommendations Glycaemic control targets should be individualized taking into account functional status, comorbidities, especially the presence of established CVD, history and risk of hypoglycaemia, and presence of microvascular complications. Discuss with the individual and principal caregiver care goals and medicine dose, regimen, and tablet burden before choosing glucose lowering agents. Use the start low and go slow principle in initiating and increasing medication and monitor response to each initiation or dose increase for up to a 3 month trial period. Consider discontinuing ineffective and unnecessary therapies.

29 Glucose control by category Functionally independent target HbA1c is % (53 59 mmol/mol) Functionally dependent target HbA1c of up to 8.5% (70 mmol/mol) may be appropriate End of life care Minimize hypoglycaemia and symptomatic hyperglycaemia Consider appropriate withdrawal of therapy, including insulin, in the terminal stages

30 Evidence base Whilst the evidence is increasing that blood pressure and lipid reduction also have specific benefits in older people above the age of 70 years, the evidence for tight glucose control is not available. Furthermore, recent studies are suggesting that a higher target glycated haemoglobin (HbA 1c ) range may be more appropriate and safer. Improved glycaemic control appears to have minimal effect on CVD in the medium term and can take up to 20 years to show a significant reduction in coronary artery disease outcomes. The ACCORD study reported that attempts at aggressive improvement in glycaemic control increased mortality The emphasis is on achieving glycaemic levels that prevent and minimize vascular complications of diabetes but also minimize the risk of hypoglycaemia.

31 Individual agents metformin Preferred first line agent in older people (REACH) registry showed overall lower 2 year mortality in people with atherothrombosis treated with metformin vs. without metformin egfr reduce dose at 45, stop at 30 GI side effects Care with dehydration states

32 Sulphonylureas Do not use glibenclamide! Gliclazide has lowest risk of hypoglycaemia Sulfonylureas are a good choice for older adults who eat consistently and are able to recognize and treat hypoglycaemia appropriately. (IDF) Consider alternatives in drivers and those living alone and egfr less than 45

33 Safe Drivers A concerned pensioner rang her 90 year old husband whilst he was driving. 'Albert, be careful, they've just said on the radio there's someone driving the wrong way on the M6' 'Im on the M6 now' he replied. 'But there's not just one going the wrong way there's hundreds of them!'

34 Glinides The glinides (repaglinide and nateglinide) are rapid acting insulin secretagogues with a shorter half life (60 90 minutes) compared with sulfonylureas. These medicines need to be taken just before meals and can be skipped if meals are skipped, thus avoiding hypoglycaemia in frail older people or those with dementia with irregular eating habits.

35 Glitazones (TZD) Weight gain / fluid retention Fractures Heart failure Bladder cancer risk largely disproved (JAMA. 2015;314: , , )

36 DPP4 inhibitors Safe in elderly Safe in impaired renal function (dose may need adjusting) Low risk of hypoglycaemia Weight neutral Recent studies demonstrated CV safety (TECOS)

37 GLP1 RA Limited data for use in older people Once weekly preparations available Expensive GI side effects common Weight loss may be disadvantage in older people ELIXA study (2015) showed CV safety (lixisenatide)

38 SGLT2 inhibitors Experience limited in elderly Increased risk of urinary and genital tract infections Less effective in renal insufficiency Hypovolaemia, postural hypotension, and weight loss may limit their use in some older people. DKA (recent FDA warning) Does EMPA REG change everything?

39 Insulin A recent analysis of pooled data from randomized studies has shown that the relative contribution of basal hyperglycaemia is lower and that of postprandial hyperglycaemia is greater in older compared with younger people at all HbA 1c levels In older people with diabetes, the type of insulin (basal, premixed, prandial) now provides flexibility to tailor treatment regimens to individual needs. Recent Cochrane review showed neither short acting or long acting preparations demonstrated superiority Prandial insulin, especially when used in a complex regimen strategy, may increase risk of errors in older people.

40 Blood pressure general The diagnosis of hypertension should be based on at least three different blood pressure measurements, taken on more than two separate visits. A diagnosis of hypertension is established by demonstrating a SBP 140 mmhg and/or a diastolic blood pressure (DBP) 90 mmhg on at least two occasions. Renal function and electrolytes should be monitored at the commencement of pharmacotherapy.

41 BP control by category Functionally independent These individuals should be managed to achieve a target blood pressure of less than 140/90 mmhg Functionally dependent atarget blood pressure of up to 150/90 mmhg may be appropriate Care with diuretics in the frail increased falls, inconvenient micturition End of life Unless the blood pressure readings are immediately life threatening, strict control of blood pressure may not be necessary, and withdrawal of blood pressure lowering therapy may be appropriate.

42 Evidence Treating hypertension reduces the risk of stroke and other adverse cardiovascular events. A 2011 meta analysis of randomized controlled trials in hypertensive people aged 75 and over concluded that treatment reduced cardiovascular morbidity and mortality and the incidence of heart failure, even though total mortality was not affected. Hypertensive people with diabetes are also at increased risk for diabetes specific complications including nephropathy and retinopathy. Results of the ACCORD blood pressure trial among people older than 65 years of age found no additional benefit of a target systolic pressure less than 120 mmhg compared with a target of 140 mmhg.

43 Individual agents ACE inhibitors should be considered the medication of choice in older people with diabetes. ARBs are a proven alternative and can be used if ACEi not tolerated. Beta blockers can be considered, especially in people with an elevated pulse rate. The main concern is the masking of hypoglycaemic symptoms. CCBs reduce cardiovascular events in people with diabetes and hypertension. However, they have been shown to be inferior to other agents in reducing some cardiovascular outcomes. Alpha blockers may be helpful in older people as add on therapy, especially in men with prostate enlargement.

44 Lipid control general Assessment of lipids is an integral part of cardiovascular risk assessment. A full lipid profile, including total cholesterol, LDL cholesterol, HDLcholesterol, and triglycerides should be assessed initially and then at clinically relevant intervals. All older people with diabetes are at high CVD risk and should be considered for treatment with a statin unless contraindicated or considered clinically inappropriate. Lower statin doses should be used and indications of side effects (especially muscular and hepatic) or possible drug interaction monitored.

45 Lipid control by category Functionally independent These individuals should be actively managed to reduce CVD risk. All treatment options generally apply to this category with statins as firstline therapy. Functionally dependent The principles are as for Category 1: Functionally Independent. Caregivers should be provided with sufficient knowledge and support to arrange the safe administration of lipid lowering therapy and monitor side effects. End of life care Lipid lowering therapy is not usually necessary, and withdrawal of therapy may be appropriate.

46 Evidence Lowering serum cholesterol by 1 mmol/l reduces risk of coronary heart disease mortality by 50% in people aged years while the risk reduction is 33% in those aged years and 15% in those aged years Although relative risk reduction decreases with age, the absolute effects of lower cholesterol on coronary heart disease reduction in older subjects are greater due to the higher prevalence of atheroma and CVD. However evidence for benefits of treatment in people aged over 80 years is limited and clinicians need to make decisions based on individualized management.

47 Statins Statins are most beneficial for preventing cardiovascular events in people who already have coronary heart disease and reduce vascular events and mortality In older adults, exposure to higher doses of statins or higher potency statins does not increase their effectiveness, but does increase the risk of adverse effects such as myopathy and cognitive impairment. The effect of statins on cognition are conflicting. In people with dementia, statins do not significantly affect cognitive decline, global function, behaviour or activities of daily living. However one study has reported that statin withdrawal was associated with improvements in cognitive function in people with Alzheimer s disease and rechallenge with statins was associated with a decline in cognition function

48 End of life care The main principles of diabetes care at the end of life include; Provision of a painless and symptom free death Tailoring blood glucose therapies Avoidance of metabolic complications such as DKA and hypoglycaemia Avoidance of dehydration Medications, including glucose lowering medications and insulin may need to be reduced or stopped as the patient with diabetes progresses through the end of life stages Changes in eating pattern, activity levels and renal function may need to be taken into consideration

49 Medications The dose of metformin, gliptins and SGLT2 inhibitors needs to be reviewed in the face of changing renal function. Sulphonylurea dose should be reviewed if dietary intake is reduced this may also be the case with GLP 1 analogues. Insulin doses may need to change with changes in renal function Hypoglycaemia risk will need to be considered with changes in eating patterns. Equipment for insulin delivery may need to be reassessed if physical capabilities alter.

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