Diabetes Mellitus in Older Adults Medha Munshi, M.D. Joslin Diabetes Center Beth Israel Deaconess Medical Center Harvard Medical School Presenter Disclosure Information Medha Munshi Research grant from Sanofi Goals and Objectives Older patients vs younger adults Goals of treatment Management strategy 1
Diagnosed and Undiagnosed Diabetes 30 25 20 Percentage 15 10 5 2010 0 20-44 45-64 65 and over 2005-2008 NHANES: national diabetes fact sheet 2011; CDC Case History 85 years old patient with diabetes Questions: - what is different in presentation? - when does this patient need treatment? - what is the best treatment for this patient? 2
Heterogeneity in Environment In Older Adult With Diabetes Community living Assisted care facilities Nursing home Alone spouse Highly functional Functionally disabled Other Family member Older adult With diabetes Co-morbidities in Aging and Diabetes Aging Macro/Micro vascular dz Cognitive dysfunction Depression Physical disability Polypharmacy Diabetes Cognitive Dysfunction Executive Dysfunction Frontal lobe mediated higher functions Insight in to the problem Planning and judgment Problem solving Starting, changing or stopping behavior 3
Case History Mr. D 82 yo male Engineer computer savvy DM duration 17 yrs Glargine BID and lispro before meals A1C 6.5% Instruction Form: Response Form: Modified Clock-In-a-Box(CIB) Please read and do the following carefully: In the blue box on the next page: Draw a picture of a clock Put in all the numbers Set the time to ten after eleven. Hand this sheet back and go to the next page Cognitive Dysfunction in Older Adults With and Without DM 40 35 30 25 20 15 10 5 0 18.5 Older Adults without DM 34 Older Adults with DM >70 yrs Munshi et al. Diabetes Care. 2006;29(8):1794-1799. Health and retirement study (CDC). 4
A1C Cognitive Dysfunction Associated with Poor Diabetes Control 8.8 8.6 8.4 8.2 8 7.8 7.6 7.4 7.2 7 6.8 Cognitive Dysfunction Cognitively Intact P<0.002 Munshi et al. Diabetes Care. 2006;29(8):1794-1799 Depression in Older Adults With and Without DM 40 35 30 32 35 Men Women 25 20 18 15 10 11 5 0 Older Adults without DM Older Adults with DM Munshi et al. Diabetes Care. 2006;29(8):1794-1799. Health and retirement study (CDC). Depressive Symptoms Associated with Increased Risk of Functional Disability 6 5.5 P<0.03 5 4.5 * 4 3.5 3 Without Depression With Depression Munshi et al. Diabetes Care. 2006;29(8):1794-1799. 5
For Women Living Alone, Glycemic Control Worsens as Number of Medications Increases A1C 9.50 9.00 8.50 8.00 7.50 7.00 6.50 6.00 5.50 5.00 0 5 10 15 20 Medication Count Hayes M et al; Diabetes 2006; A212 Functional Impairment in the Elderly With Diabetes Hearing Impairment 48 % Vision Impairment 53 % History of Recent Falls 33 % Fear of Falls 43 % Independent in ADL 95 % Independent in IADL 38 % Munshi et al. Diabetes Care. 2006;29(8):1794-1799. Complex Interactions in Older Adults with Diabetes Morbidity and Functional Disability Hypoglycemia Compliance Quality of life CAD CVD PVD Cognitive Dysfunction Depression Poly pharmacy Neuropathy Retinopathy Nephropathy Falls Urinary Incontinence Physical Disability Diabetes Mellitus Morbidity Mortality 6
Management of Diabetes in Older Adults Screening for barriers Clinical / Functional / Psychosocial Management of hyperglycemia Medications Diet Exercise/Physical activity Management of risk factors BP control <130/80 mm Hg LDL cholesterol <100 mg/dl Cessation of cigarette smoking Low dose aspirin therapy Yearly screening for microalbuminuria (ACE inhibitors), retinopathy, foot examination Goal- Setting Glycemic Goal Hypoglycemia Social support and Living situation Financial issues Life expectancy Physical abilities A1C: Marker of Glycemic Control Increases with increasing age Affected by red cell life span Role of renal dysfunction and anemia of chronic diseases not known Reflects average glucose miss BG fluctuations 7
A1C - 8.2% Insulin only A1C - 8.3% Insulin and oral Hypoglycemia in older adults Insulin therapy in older adults Hypoglycemia unawareness Cognitive dysfunction interfering with identification/treatment of hypoglycemia Co-morbidities mimicking hypoglycemic symptoms Hypoglycemia & Fear of hypoglycemia Noncompliance Falls, hospital visits Exacerbation of chronic conditions Even mild hypoglycemia may result in poor outcome Frequent Hypoglycemic Episodes Detected by CGM age>70 yrs; A1C>8%; n=40 Patients with hypoglycemia n = 26 (65 %) Patients with A1C 8-9 % 14 (54 %) Patients with A1C > 9 % 12 (46 %) Severity of hypoglycemic episodes 60-69 mg/dl 100 % 50-59 mg/dl 73 % < 50 mg/dl 46 % Munshi et al; Arch Intern Med. 2011;171(4):362-364 8
Diabetes Care. 2012 Dec;35(12):2650-64 J Am Geriatr Soc. 2012 Dec;60(12):2342-56 A Framework for Treatment Goals Patient characteristics /health status Rational A1C BP Lipids Healthy - few co-existing illnesses - intact cognitive status - intact functional status Complex/Intermediate - Multiple co-existing illnesses - Mild-moderate cognitive impairment - 2+ instrumental ADL Very Complex/Poor Health - LTC care residents - end-stage chronic illnesses - Moderate-severe cognitive impairment - 2+ ADL dependencies Longer life expectancy Intermediate life expectancy High treatment burden Hypo vulnerability Fall risk Limited life expectancy Benefits uncertain <7.5% <140/80 Statins unless not tolerated <8% <140/80 Statins unless not tolerated <8.5% <150/90 Consider risks and beneftis Kirkman MS et al; Diabetes Care. 2012 Dec;35(12):2650-64 Goal-setting Algorithm in Elderly Current A1c <7% 7 8% > 8% Multiple Few Comorbidities Comorbidities or and medications Medications that may unlikely to cause cause hypoglycemia hypoglycemia Medications likely to cause hypoglycemia Carefully assess for hypoglycemia or glucose excursions Medications unlikely to cause hypoglycemia Present -Multiple Co-morbidities -Limited Life Expectancy -Difficulty coping Not Present Present Not Present Liberalize Goal At goal with caution (Continually assess for hypoglycemia) At Goal Aim for Goal < 8% 9
15 Classes of Antidiabetes Medications Class A1C Fasting Reduction vs PPG Weight Gain Dosing (times/day) Other Safety Issues Metformin 1.5 Fasting No Neutral/ 2 GI, lactic acidosis Loss Insulin (long-acting) 1.5 2.5 Fasting Yes Gain 1, Injected Insulin (rapid-acting) 1.5 2.5 PPG Yes Gain 1 4, Injected Sulfonylureas 1.5 Fasting Yes Gain 1 Allergies, secondary failure Thiazolidinedione s GLP-1 agonist (short-acting) 0.5 1.4 Fasting No Gain 1 Edema, CHF, bone fractures 0.5 1.0 PPG No Loss 2, Injected GI, ARF,?pancreatitis Repaglinide 1.0 1.5 Both Yes Gain 3 Nateglinide 0.5 0.8 PPG Rare Gain 3 ARF = acute renal failure; GI = gastrointestinal; GLP = glucagon-like peptide Adapted from Nathan DM et al. Diabetes Care. 2007;30:753-759. Nathan DM et al. Diabetes Care. 2006;29:1963-1972. Nathan DM et al. Diabetes Care. 2009;32:193-203. ADA. Diabetes Care. 2008;31:S12-S54. I WelChol PI. 1/2008. Cycloset PI. 5/2009. Buse JB et al. Lancet. 2009;374:39-47. 15 Classes of Antidiabetes Medications Class A1C Fasting Reduction vs PPG Hypoglycemia Hypoglycemia Weight Gain Dosing (times/day) Other Safety Issues α-glucosidase 0.5 0.8 PPG No Neutral 3 GI inhibitor Amylin mimetics 0.5 1.0 PPG No Loss 3, Injected GI DPP-4 inhibitors 0.6 0.8 Both No Neutral 1?pancreatitis Bile-acid 0.5 Fasting No Neutral 1 2 GI sequestrant Bromocriptine 0.7 PPG No Neutral 1 GI GLP-1 agonist (long-acting) (SGLT-2 inhibitors) 1.0 1.5 Both No Loss 1, Injected GI,?pancreatitis,?MTC,?ARF <1 Both No Loss 1?? ARF = acute renal failure; DPP-4 = dipeptidylpeptidase-4; GI = gastrointestinal; GLP = glucagon-like peptide; MTC = medullary thyroid cancer; SGLT-2 = sodium-glucose transporter-2 Adapted from Nathan DM et al. Diabetes Care. 2007;30:753-759. Nathan DM et al. Diabetes Care. 2006;29:1963-1972. Nathan DM et al. Diabetes Care. 2009;32:193-203. ADA. Diabetes Care. 2008;31:S12-S54. I WelChol PI. 1/2008. Cycloset PI. 5/2009. Buse JB et al. Lancet. 2009;374:39-47. Insulin Action 10
Higher contribution of post-pradial glucose in hyperglycemia in older vs younger adults Munshi et al, J Am Geriatr Soc. 2013;61:535 541 Diagnosis Normal Renal function Abnormal Algorithm for the metabolic management of older adults with diabetes Metformin Start @ 500 mg/d Increase by 500 mg Up to 2000 mg/d DPP 4 inhibitors Sulfonylurea Start low and Increase dose as tolerated No CHF Normal LFT GLP- 1 agonist Add second and/or third agent as needed Cognitive function TZDs Algorithm for the metabolic management of older adults with diabetes Post prandial hyperglycemia Long acting insulin Am dosing Uncontrolled With oral Meds High FBS Long acting insulin Pm dosing Or NPH at bedtime -Low AM, high PM -memory loss -Long acting and NPH or mix insulin in am 11
Use of serum c-peptide to simplify regimen in older adults Normal/high serum C-peptide: 65/100 Age: 79±14 yrs, DM duration: 21±13 yrs Number of medications: 11 (range 4-18) Simplification completed in 35 patients In 19 patients, patients completely off insulin In 16 patients number of insulin injections were decreased significantly Number of hypoglycemic episodes decreased A1c improved from 8% to 7.4% (p<0.002) Munshi et al; American Journal of Medicine 2009;122;395-97 Simplification of Regimen Improves Glucose Excursions A1c 7.5% Aspart Mix 70/30 30 units BID Time < 70mg/dL: 590 min Metformin 1000mg QAM, 500mg QPM A1c 7.2% Time < 70mg/dL: 0 min Glargine 40 units QAM Metformin 1000mg BID Munshi et al; abstract presentation at ADA June 2013 Summary Older patients vs younger adults Clinical presentation is variable Goals of treatment Consider co-existing conditions Risks vs Benefit of treatment A1c vs hypoglycemia - parameters for glycemic goals Management strategy Matching patients coping skills to the complexity of the treatment KISS 12