Older Adults & Optimal Outcome Individualizing Diabetes Management Mary Moyer Janci BC-FNP BC-ADM CDE Teaching Associate Diabetes Care Center UWMC
What is Diabetes? METABOLIC DISEASE Food breakdown (carbohydrates, proteins and fat) fuel for the body ABNORMAL 2
GLUCOSE STIMULATED INSULIN SECRETION HEPATIC GLUCOSE RESPONSE GLUCOSE UPTAKE BY MUSCLE & FAT Controlled glucose clearance. Enters peripheal tissue. Controlled glucose production. Enters blood. NORMAL PLASMA GLUCOSE 3
GLUCOSE STIMULATED INSULIN SECRETION GLUCOSE UPTAKE BY MUSCLE & FAT Controlled glucose clearance. Enters peripheal tissue. Controlled glucose production. Enters blood. 4
Diabetes Types Type 1, 1.5, LADA Type 2 Adult Secondary Diabetes Disease/injury to the pancreas - pancreatitis, pancreatectomy, CFRD Meds increased insulin resistance» STEROID INDUCED HYPERGLYCEMIA
T2DM Pathophysiology Peripheral insulin resistance in muscle and fat Decreased pancreatic insulin secretion Increased hepatic glucose output Risk fx: African Americans, Latinos, American Indians, Alaska Natives, Asian Americans, Pacific Islanders PEARL: oral agents or insulin
T1DM Pathophysiology Decreased pancreatic insulin secretion Peripheral insulin resistance in muscle and fat Increased hepatic glucose output PEARL: only insulin Haffner SM, et al. Diabetes Care, 1999
What makes older adults at risk for diabetes? Decreased beta cell function with loss of first phase insulin shows up in post prandial blood glucose AND Loss of muscle mass Decreased physical activity Increased adiposity
What factors affect quality of life? Changes in cognitive status Decrease ability to care for myself Increase in use of caregivers Decrease life expectancy Huang et al. J AM Geriatr Soc 2005;53:306-311
How does glycemic control affect the body? Hypoglycemia Increase in Hypoglycemia unawareness Cognitive changes / confusion Need assistance to treat lows Falls & unsteady gait More admissions to hospital? Cardiac events Hyperglycemia Dehydration Urinary incontinence Electrolytes Dizziness/ falls More admissions to hospital from HHS, infection
Recommendations for the Comprehensive Care of Older Patients With T2D: Consensus Panel Framework presented Fasting ADA or conference 2012 Health Status Rationale Reason-able A1C Goal Preprandia l Glucose (mg/dl) Bedtime Glucose (mg/dl) Blood Pressure (mm Hg) Lipids Healthy Longer life expectancy <7.5% 90 130 90 150 <140/80 Statin (unless contraindicated or not tolerated) Complex/ Intermediate Health Intermediate life expectancy; high treatment burden; hypoglycemia vulnerability; fall risk <8.0% 90 150 100 180 <140/80 Statin (unless contraindicated or not tolerated) Very Complex/ Poor Health Limited life expectancy; treatment benefit uncertain <8.5% 100 180 110 200 <150/90 Consider benefit with statin; (secondary prevention > primary) Healthy: few coexisting chronic illnesses, intact cognitive and functional status. Complex/Intermediate Health: multiple coexisting chronic illnesses, or 2+ instrumental ADL impairments, or mild to moderate cognitive impairment. Very Complex/Poor Health: long-term care or end-stage chronic illnesses or moderate to severe cognitive impairment or 2+ activities of daily living dependencies. 13 Kirkman S et al. Diabetes Care. 2012;35(12):2650 2664.
What are we dealing with? 1,2 Older adult stats: 65 years + 72.1 million 2030 ~ 19% population 85 years + 5.5 million 2007 6.6 million 2020 Today ~ 26% adults > 65 years have diabetes 1. US Dept of Health Human Services, Admi on Aging. www.aoa.gov/aoaroot/aging_statistics/profile 2. http://www.cdc.gov/diabetes/pubs/statsreport14/national-diabetes-report-web.pdf
What do most aging adults want? INDEPENDENCE For ADLs Exploratory study T2DM 65+ n=28 71% ranked Independence and ADLS as top priority What takes away independence? Polypharmacy too many meds to manage LEADS TO increased side effects Higher risk of hypoglycemia due to length of time with DM Increased CVD Decreased kidney function Huang et al. J AM Geriatr Soc 2005;53:306-311
Treatment Goals Improving quality of life & quality of care Allowing choices in daily living Assisting individuals to make informed health decisions ADA. Older adults. Sec. 10. In Standards of Medical Care in Diabetes-2016. Diabetes Care 2016.:39 (Suppl.1):S81-S85
Recommendations for the Comprehensive Care of Older Patients With T2D: Consensus Panel Framework Health Status Rationale Reasonable A1C Goal Fasting or Preprandial Glucose (mg/dl) Bedtime Glucose (mg/dl) Blood Pressure (mm Hg) Lipids Healthy Longer life expectancy <7.5% 90 130 90 150 <140/80 Statin (unless contraindicated or not tolerated) Complex/ Intermediate Health Intermediate life expectancy; high treatment burden; hypoglycemia vulnerability; fall risk <8.0% 90 150 100 180 <140/80 Statin (unless contraindicated or not tolerated) Very Complex/ Poor Health Limited life expectancy; treatment benefit uncertain <8.5% 100 180 110 200 <150/90 Consider benefit with statin; (secondary prevention > primary) Healthy: few coexisting chronic illnesses, intact cognitive and functional status. Complex/Intermediate Health: multiple coexisting chronic illnesses, or 2+ instrumental ADL impairments, or mild to moderate cognitive impairment. Very Complex/Poor Health: long-term care or end-stage chronic illnesses or moderate to severe cognitive impairment or 2+ activities of daily living dependencies. 17 Kirkman S et al. Diabetes Care. 2012;35(12):2650 2664.
Case Study- What to do? Use our tools Interview patient in decision-making. MMSE Individualize Patient Goals Adjust target A1C based on chronic conditions, lifespan, mental capability Prioritize targets: BP, Lipids, A1C Customize treatment plan: meds, diet, exercise, caregiving
2 nd TOOL: RANKING A1 c More or less stringent glucose control? Inzucchi S E et al. Dia Care 2012;35:1364-1379
3 rd TOOL: Priorities A1c 8..2% LDL 128 Physiologic Length of Outcome Research Physiologic Time to see Outcome Parameter time Parameter benefit of tx needed to see benefit Blood glucose of tx 8 years Reduced Blood glucose 1. microvascular disease, microvascular 1. UKPDS 8 years mortality & MIs disease 2. Neutral CVD, MI stroke mortality Reduced CV dx Lipids 2-3 3. years Neutral CVD, kidney Reduced stroke and MI morbidity and mortality disease 4. Neutral CVD, albuminuria Blood pressure 2-3 Reduced years stroke Reduced stroke mortality and MI morbidity and mortality studies Lipids 2-3 years Blood pressure 2-3 years 2. ACCORD (stop 3 yrs) 3. ADVANCE 4. VADT No large trials Meta-analysis of smaller 1. Reduced stroke 1. ACCORD-BP Kirkman S et al. Diabetes Care. 2012;35(12):2650 2664. 2. Reduced mortality 2. VADT BP 138/64
Recommendations for the Comprehensive Care of Older Patients With T2D: Consensus Panel Framework Health Status Rationale Reasonable A1C Goal Fasting or Preprandial Glucose (mg/dl) Bedtime Glucose (mg/dl) Blood Pressure (mm Hg) Lipids Healthy Longer life expectancy <7.5% 90 130 90 150 <140/80 Statin (unless contraindicated or not tolerated) Complex/ Intermediate Health Intermediate life expectancy; high treatment burden; hypoglycemia vulnerability; fall risk <8.0% 90 150 100 180 <140/80 Statin (unless contraindicated or not tolerated) Very Complex/ Poor Health Limited life expectancy; treatment benefit uncertain <8.5% 100 180 110 200 <150/90 Consider benefit with statin; (secondary prevention > primary) Healthy: few coexisting chronic illnesses, intact cognitive and functional status. Complex/Intermediate Health: multiple coexisting chronic illnesses, or 2+ instrumental ADL impairments, or mild to moderate cognitive impairment. Very Complex/Poor Health: long-term care or end-stage chronic illnesses or moderate to severe cognitive impairment or 2+ activities of daily living dependencies. 21 Kirkman S et al. Diabetes Care. 2012;35(12):2650 2664.
4 th TOOL: Use the Medication Chart
Diabetes Medication Target Population Benefits Risks Dose Adjustment for CKD Stage 3-5 Dialysis COST Sulfonylureas - glipizide, glyburide, glimeperide T2DM < 5 years insulin secretion microvascular (UKPDS) More hypos; weight gain Glimeperide: decrease dose; 1 mg/day recommended Glipizide: no decrease in dose Glyburide: avoid DIALYSIS- GLIPIZIDE ONLY LOW Meglitinidesrepaglinide, netaglinide Recent diagnosis T2DM, Elevated PPG Short acting, less hypoglycemiq Flexible dosing based on size of meal, More hypos Weight gain Frequent dosing Repaglinide: no decrease in dose Nateglinide: start at low dose of 60 mg DIALYSIS- REPAGLINIDE ONLY MOD- HI Biguanidesmetformin, glucophage Overweight, obese, IR No wt gain, less hypoglycemia CVD events UKPDS GI side effects, rare lactic acidosis Contraindicated: males SCr > 1.5 mg/dl; females: SCr> 1.4 mg/dl Consider s crt 1.7/egfr<30 dose reduction DIALYSIS- AVOID LOW TZDs- *** rosiglitazone, pioglitazone Overweight, obese, IR insulin sensitivity No hypos HDL Weight gain/fluid retention, slow onset, Bone fx No dose adjustment for either med DIALYSIS OK LOW DPP-4 *** Sitagliptin Saxagliptin Vildaliptin Alogliptin Linigliptin insulin glucagon No hypoglycemia Angioedema, urticarial,? Pancreatitis?HF 25% GFR 30-50 50% GFR < 30 DIALYSIS OK HI
Diabetes Medication Target Population Action/ Benefits Risks Dose Adjustment for CKD Stage 3-5 Dialysis COST GLP-1 RA *** Exenatide/ ER Liraglutide Abiglutide Lixsenatide Dulaglutide Overweight, obese No hypoglycemia Wt loss PP glucose some CV risk fx GI side effects Injectable Pancreatitis? Change thyroid tumors in animals Avoid egfr <30 HI Alphaglucosidase inhibitoracarbose, miglitol No hypoglycemia PP glucose Elevated post meal glucose Slow intestinal carb digest/absorp GI side effects, low impact of A1c Avoid SCr > 2 mg/dl DIALYSIS AVOID MOD SGLT2 inhibitors *** Canagliflozin Dapagliflozin Empagliflozin Block glucose reabsorption glycosuria No hypos wt BP No hypos Euglycemic DKA GU infections Polyuria Hypotension/volume depletion Dizziness Adjust dose in egfr <59 Avoid in egfr < 30 HI New Insulins Hypos Injectable needs training Adjust dose by 25-50% in patients with decreased kidney function HI
Insulin & Older Adults US Public Health survelliance data of people 65 years Insulin was one of top meds ADRs ER visits 40% of these pts were hospitalized What do we learn? careful selection of patients, training for insuln and smbg, regular follow up Budnitz et al. N Engl J Med. 2011:365:2002-2012
Case Study- Lifestyle Changes and Education Lifestyle changes Exercise Nutrition Education 1:1 Blood Glucose Monitoring Testing daily in the fasting state 2 hour post meal testing after the largest meal Diabetes Core Classes 10 hour program focusing on diabetes, meds, nutrition ADA certified Individualized Training. Bring a family member or caregiver.
Nutrition Older adults at risk for poor nutrition & weight loss Causes: loss of smell, taste, hormonal changes that control satiety American Dietetics Association Refer to RD for individualized care plan Involve patient, family, team members in choices Base on patient s condition & life span Some changes may include: Less restrictive diet More carbohydrate beverages Position of the ADA Assoc; Ethical and legal issues in nutrition, hydration, and feeding. J Am Diet Assoc. 2008; 108:873-882
Research to support lifestyle changes DPP & Look AHEAD 1 Found wt loss & physical activity glucose older adults had > wt loss & more physical activity than younger pts and not associated with intensity of exercise. So bottom line: don t have to run a marathon or be on Biggest Loser TV show Exercise & healthy eating for planned weight loss 2 Increases muscle mass Improves functional status Improves depression? decrease urinary incontinence 1. Espelnad et all. JAGS: 61:912-922, 2013. 2. American Heart Asso. 2014. http://www.heart.org? improve CV risk factors
Update Case Study 5 years later 87 yo Patient returns to clinic with A1c 9%. CABG with 2 vessel bypass, HTN, Hyperlipidemia, developing cognitive impairment Now living in ALF TREATMENT PLAN: changing the meaning of optimal? Options? Decreased risk of hypos with meds; changed target to A1c <8.5% Added basal insulin in AM & stopped DPP4 due to $$$-??? Now low dose TZD or NPH? Continue metformin? Add sulfonylurea?
Palliative Care Proposed Recs Goals: comfort, symptom control, prevention of pain, hyperglycemia/hypoglycemia, dehydration; preservication of diginity and quality of life (1) Patient has the right to refuse testing & treatment Stable patient: focus on preventing hi/lo bgs (2) Organ failure patient: focus on preventing bg lows; (2) tx highs with hydration as tolerated. T1DM require insulin but may simplify. T2DM my titrate off insulin. 1. J Am Med ir Assoc 2012, 13:497-502 2. J Palliat Med 2011; 14:83-87
Summary REMEMBER INDIVIDUALIZE DIABETES GOALS IN OLDER ADULTS USE TOOLS Interview for patient priorities Set medical priorities Lipids, BP, A1c Set target A1c / bg control by using ranking scales Use diabetes med chart Add lifestyle changes Re-evaluate routinely Re-adjust diabetes goals based on patient / family priorities, physical and mental condition, lifespan