Diabetes And The Older Adult
Diabetes and the Older AdultTony Hampton, MD, MBA
Disclosures Presenter disclosures, if any, listed here.
Learning Objectives Define the present and future epidemiology ofdiabetes and its complications in older adults Discover screening, diagnostic, and preventionstrategies for diabetes in older adults Discuss individualization of care and prevention ofdiabetes in older adults Identify best practices to involve patients indecisions related to diabetes care in older adults
Epidemiology of Diabetes in Older Adults More than 25% of the US population over 65 hasdiabetes Half over 65 have prediabetes Postprandial hyperglycemia is common in olderadultsCenters for Disease Control and Prevention. National Diabetes Fact Sheet: General Information and National Estimates on Diabetes in the United States. Atlanta,Georgia, U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, 2011.Kirkman MS. Diabetes in Older Adults ADA Consensus Report. Diabetes Care 2012.
Onset 65 Years vs. Middle AgeMiddle Age OnsetOlder Onset Shorter diabetes durationLower mean A1CLower insulin useLower incidence ofretinopathy Longer diabetes durationHigher mean A1CHigher insulin useHigher incidence ofretinopathyNo difference in prevalence of cardiovascular disease(CVD) or peripheral neuropathySelvin E, et al. Diabetes Care 2006; 29:2415-19.
Number of persons 65 Exponential Growth of Adults 65 in the USPopulation 65 by Age: e85 60,000,00040,000,000One out of every five20,000,00001900 1910 1920 1930 1940 1950 1960 1970 1980 1990 2000 2010 2020 2030 2040 2050Yearwww.aoa.gov/Aging Statistics/future growth/future idence/fig5.htm
Percent prevalence of T2DM454035302520151050Know Your Patient Population:Recognize Disparities201145-6465-7475 White menWhitewomenBlack men Black women Asian men Asian womenRace and genderCenters for Disease Control and Prevention. Percent US Population with Diagnosed Diabetes, by Age, Race and Sex. 2011.
Diagnosis of Diabetes in All Adults Criteria do not change with age Diagnosis based exclusively on hyperglycemia Three methods used to determine dysglycemiaHbA1cFasting GlucoseOGTT(2 hr. glucose) 6.5% 126 mg/dL(7 mmol/L) 200 mg/dL(11.1 mmol/L)PREDIABETES5.7–6.4%100–125 mg/dL(5.6–6.9 mmol/L)140–199 mg/dL(7.8–11.0 mmol/L)NORMAL 5.6% 100 mg/dL(5.5 mmol/L) 140 mg/dL(7.7 mmol/L)DIABETESSacks DB, et al. Clin Chem 2011; 57:147-9.
Screening in Older Adults ADA recommends screening adults 45 years every oneto three years– Use FPG test, A1C, or oral glucose tolerance test Annual screening for early detection of mild cognitiveimpairment or dementia in adults 65 years of age Adults 65 years of age with diabetes should beconsidered a high priority population for depressionscreening and treatmentAmerican Diabetes Association. Diabetes Care 2017; 40(Suppl. 1):S99-104.
Highest Rates of ComplicationsAge 65-74 More cardiovascular disease More lower extremity amputations More nonretinopathy visual impairment More end-stage renal disease Hyperglycemic crisis deathAge 75 also experience More complications 2x rate of ER visits due to hypoglycemiaLi Y, et al. Diabetes Care 2012; 35:273-77.Centers for Disease Control and Prevention. Diabetes Public Health Resource.
Heterogeneity of Older Adults with DiabetesRELATIVELYHEALTHYDIFFICULT TOIMPLEMENT 3 chronic diseases 3 chronic diseases No cognitive or Mild cognitivesignificant visualimpairment 0 or 1 of instrumentalactivities of daily living(IADL) dependenciesBlaum C, et al. Medical Care 2010; 48(4):327-34.impairmentLIMITED BENEFIT Moderate to severecognitive impairment 2 IADL dependencies Severe vision Residence in a long-impairmentterm nursing facility 2 IADL dependencies
Diabetes and Geriatric SyndromesVision/hearingimpairmentGait problemsand ening Functional Impairments and DisabilityLaiteerapong N, Karter AJ, Liu JY, et al. Diabetes Care 2011; 34:1749-53.
ASSOCIATED CONDITIONSDiabetes and Functional ImpairmentDiabetic eye diseaseDiabetic foot disordersObesityDepressionHigh blood pressureLow education levelLow income levelFunctionalImpairmentGreater disabilityDelayed recoveryHospitalizationNursing home stays
Assessments for Physical FunctionNAMECONTEXT10 MeterWalk Test(10MWT)Tests short duration walkingspeed; tests gait and functionalmobilityTimed Up &Go Test(TUG)Assesses mobility, balance,walking ability, and fall riskBarthel Index(BI)Assesses the ability to perform10 activities of daily living(ADL)Four StepSquare Test(FSST)Test of dynamic balance;clinically assesses ability tochange directions whilesteppingRehabilitation Measures Database. www.rehabmeasures.orgSTRENGTHSEasy/quick to administer ( 5 mins.)Assistive devices can be usedEasy/quick to administer ( 5 mins.)Excellent test-retest reliability andcorrelation with other assessmentsEasy/quick to administer ( 5 mins.)for self-report; 20 mins. forobservationWidespread familiarity contributes toits interpretabilityEasy/quick to administer ( 5 mins.)Preferred by older adults – they feelit is relevant to daily lifeLIMITATIONSNot for patients who cannotwalk without caretakerassistanceMay demonstrate lessreliability among patientssuffering from cognitiveimpairmentNot for use with people whohaveCommunication deficits andchanges in their mentalstatusCan be difficult for impairedpatients to perform
Vision and Hearing Impairment Ophthalmologic examination at the time of diagnosis and atleast yearly thereafter to screen for diabetic retinopathy,cataracts, glaucoma Symptomatic patients with prediabetes and diabetes canbenefit from screening for hearing loss Ask, “Do you have a hearing problem now?” Refer to audiologist for thorough audiological evaluationand appropriate recommendations for aural rehabilitationJohnson CE, et al. Eye 2009; 58(9):471-7.
Assessments for Cognitive FunctionNAMECONTEXTSTRENGTHSLIMITATIONSClock Drawing Test/Mini Cog AssessmentTests executivefunctioningEasy/quick to administer( 5 mins.)Not for patients with visualimpairment or who can’t holda writing toolConfusionAssessment Method(CAM)Diagnoses deliriumwith altered mentalstatusClearly defined clinicalfeaturesDoes not identify the causeof deliriumDigit Span TestTests attention andimmediate recallEasy/quick to administer( 5 mins.)Only tests attention andimmediate recallTests multiplecognitive domainsWidely used; assessesseveral cognitive domainsAge, education, culturalbackground affect the score;insensitive to change overtimeTests multiplecognitive domainsHigher sensitivity, similarspecificity, better predictor offunctional outcome thanMMSERequires 15 mins. toadministerFolstein Mini-MentalState Exam (MMSE)Modified Mini MentalStatus Examination(3MS)
Cognitive Status Screen for cognitive dysfunction at initial work-up Periodic screening at subsequent appointments Simplify self-care regimen Interview and involve caregiversWhitmer RA, et al. JAMA 2009; 301:1565-72.Cukierman T, et al. Diabetologia 2005; 48: 2460-69.
Diabetes and Cognitive Impairment Approximately 20% of older adults with diabetes haveundiagnosed CI Alzheimer’s-type and multi-infarct dementia are two to threetimes as likely in an older adult population with diabetes T2DM is associated with medial temporal lobe atrophy andpoor performance on tests of executive function, speed,memory and attention, language and praxisVerdelho A, et al. The LADIS Study. J Neurol Neurosurg Psychiatry 2007; 78(12):1325-30.Yoshitake T, et al. Neurology 1995; 45:1161-68.Ott A, et al. Neurology 1999; 53:1937-42.
Diabetes and Cognitive ImpairmentHypoglycemiaHyperglycemiaInsulin resistanceInsulin insufficiencyNovak V, et al. Diabetes Care 2012; 34(11):2438-41.Lauder LJ, et al. ACCORD Study. Lancet Neurol 2011; 10:969-77.Whitmer RA, et al. JAMA 2009; 301:1565-72.Cukierman T, et al. Diabetologia 2005; 48:2460-69.CognitiveFunction
Depression in Older Adults with Diabetes Depression and diabetes are “synergistic” earlieronset of negative outcomes than either factor alone:- Poor glycemic control- Poor self-care- Accelerated rates of coronary heart disease- Higher occurrence of dementia- Higher mortality- Greater disability and complicationsKaton WJ, et al. Arch Gen Psychiatry 2012; 69:410-17; Katon WJ, et al. Diabetes Care 2005; 28:2668-72.Lin EH, et al. Diabetes Care 2004; 27:2154-60; Black SA, et al. Diabetes Care 2003; 26:2822-8.
Treating Diabetes in Older Adults
Management Rules of Diabetes in Older Adults Rule # 1: Individualize targets Rule # 2: Avoid hypoglycemia Rule # 3: Individualize medications
Individualization of Glycemic TargetsDiabetes Care 2017; 40(Suppl 1): S53.
Framework for Individualizing A1C Targets inOlder Adults 7.5% Reasonable A1C goal for healthy older adults 7% May be appropriate if it can be safely achieved inhealthy older adults with few comorbidities and goodfunctional status 8.5% Appropriate for older adults with multiplecomorbidities, poor health, and limited life expectancyPotential harm in lowering A1C to 6.5% in older adults withtype 2 and comorbiditiesBrown AF, et al. CHF/American Geriatrics Society (AGS) Panel. Guidelines for Improving the Care of the Older Person with Diabetes Mellitus.J Am Geri Soc 2013; 51:S265-S280.
Pharmacotherapy Carefully choose antihyperglycemic therapies with consideration ofpolypharmacy as well as patient/caregiver preferences In type 2 patients, hypoglycemia risk is linked more to treatmentstrategies than to achieved lower A1C Metformin is the preferred initial therapy in many older adults withtype 2 diabetes, but at reduced dose in those with stage 3 CKD(avoid in those with stage 4 CKD) Assess patients regularly for hypoglycemia Modify therapy and /or glycemic targets for recurrent or severehypoglycemiaKirkman S, et al. J Am Ger Soc 2012; 60(12):2342-56.Kirkman S, et al. Diabetes Care 2012; 35:2650-64.
Metformin Can be used in patients with estimated glomerular filtrationrate (eGFR) 30 mL/min/1.73 m2– If eGFR 45 mL/min/1.73 m2, do not initiate therapy, or if existingtreatment, reassess use Low cost, low hypoglycemic risk Contraindicated in advanced renal insufficiency or significantheart failure Can be temporarily discontinued before procedures, duringhospitalizations, and when acute illness may compromiserenal or liver function Associated with vitamin B12 deficiency, so periodic testingshould be consideredDiabetes Care 2017; 40 (Suppl 1): S37, S46, S66, S83, S90, S102.
Sulfonylureas HIGH RISK FOR HYPOGLYCEMIA– Avoid glyburide– Risk of hypoglycemia increases with: age 60,disability, poor nutrition, polypharmacy, renalimpairment– May have increased risk of hip fractures Shorter-duration sulfonylureas, such as glipizide arepreferred Low cost and good efficacyRajpathak et al. Drugs Aging 2015: Apr; 32(4):321-7.Diabetes Care 2017; 40 (Suppl 1): S102.
Incretin-based Therapy (GLP-1 and DPP-4) GLP-1 Receptor Agonists––––Minimal hypoglycemiaLower CVD event rate and mortality in CVD (liraglutide)May be associated with nausea, vomiting, and diarrheaHigh cost, injectable DPP-4 Inhibitors– Minimal hypoglycemia– Possible angioedema/urticaria and other immune-mediateddermatological effects– Increased heart failure hospitalizations (saxagliptin, alogliptin)– High costDiabetes Care 2017; 40 (Suppl 1): S68, S102.
TZDs Use very cautiously in those with, or at risk forcongestive heart failure (water retention) and falls orfractures (increased risk of osteoporosis) Low cost, low risk hypoglycemia Can be used in renal insufficiencyGrey A. Osteoporos Int 2008 Feb; 19(2):129-37.Lecka-Czernik B. Curr Osteoporos Rep 2010: Dec; 8(4):178-84.Diabetes Care 2017; 40 (Suppl 1): S102.
SGLT2 Inhibitors Rare hypoglycemia Oral route convenient for older adults Weight loss, lower CVD event rate and mortality inpatients with CVD (empagliflozin) Mycotic infections, potential hypovolemia, UTIDiabetes Care 2017; 40 (Suppl 1): S68, S102.
Insulin Therapy Once-daily basal insulin injection therapy has minimalside effects in many older patients Injectable – except for inhaled insulin – which may beassociated with pulmonary toxicity Effective in reducing HbA1c and fasting hyperglycemia Hypoglycemia is a common and serious complication ofdiabetes in older adults-Major contributor of emergency hospitalizationAssociated with increased risk of death and fracturesDiabetes Care 2017; 40 (Suppl 1): S68.
Antihyperglycemic Medications Basal insulin therapy– Usually prescribed with metformin and sometimes one additional noninsulinagent and without rapid-acting insulin– Minimal side effects in older adults– Risk of hypoglycemia must be carefully considered– Multiple daily injections may be too complex for older adults with advancedcomplications, life-limiting comorbidities or limitedfunctional status– T2DM patients may require mealtime bolus insulin as well; if so, considerdecreasing basal insulin doseDiabetes Care 2017; 40 (Suppl 1): S99-103.
Management in Settings Outside the Home The glycemic goals for hospitalized older adults with diabetes areusually similar to those for the general population The use of sliding scale insulin alone for chronic glycemic managementis discouraged in inpatient settings as well as in LTC facilities Transitions of older adults with diabetes (e.g. from home or LTC facilityto hospital to postdischarge setting) are periods of high risk Hypoglycemia: Assessments should be done at least every 30 days forthe first 90 days after admission and then at least once every 60 daysKirkman S, et al. J Am Ger Soc 2012 60(12):2342-56.Diabetes Care 2012; 35:2650-64.
Shared Decision-MakingKey components of the shared decision-makingapproach, include:1.2.3.4.Establishing ongoing partnership between patient andproviderExchanging informationDeliberation on choicesDeciding and acting on decisions Congruence of your patient’s goals with yourgoals for management is importantContinued Kirkman S, et al. J Am Ger Soc 2012; 60(12):2342-56.Diabetes Care 2012; 35:2650-64.
Shared Decision-Making (cont’d) Patients need to understand the plan to see value Refer to diabetes self-management education and support Know your patient’s preferences regarding treatment plan,medications, management Accommodate patient preferences when feasible and in linewith goals Caregivers/family will often relay patient’s preferences – checkwith patient directlyKirkman S, et al. J Am Ger Soc 2012; 60(12):2342-56.Diabetes Care 2012; 35:2650-64.
Hypoglycemia in Older Adults with Diabetes
Hypoglycemia in Older Adults 50% higher rates of severe hypoglycemia (requiring assistance) Earlier and more severe deterioration of psychomotorcoordination Impaired awareness of autonomic warning symptoms even wheneducated– There is loss of the usual 10–20 mg/dL difference in PG betweensubjective awareness of hypoglycemia and onset of cognitivedysfunction Risk higher in cognitively impairedKirkman MS, et al. J Am Ger Soc 2012; 60(12):2342-56.Kirkman MS, et al. Diabetes Care 2012; 35:2650-64.Bremer JP, et al. Diabetes Care 2009; 32:1513-17.
Hypoglycemia and Mortality Hypoglycemia is associated with increased risk of mortality History of severe hypoglycemia nearly doubled risk of mortalityin both ACCORD and ADVANCE Risk was greatest in ACCORD participants who could not get totarget A1C (including those in the intensive arm who did notachieve the target A1C 6.0%) Five year f/u study at Mayo Clinic of 1000 patients (mean age60) showed those with a history of severe hypoglycemia atbaseline had OR for mortality of 3.38 at five years (95% CI:1.55–7.38, p 0.005)McCoy DC. Diabetes Care 2012 Sep; 35(9):1897-901.
Hypoglycemia in Older Adults Risk factors for hypoglycemia in older adults include:-Use of insulin or insulin secretagoguesLonger duration of diabetesHistory of antecedent hypoglycemiaErratic mealsRenal insufficiencyHospital discharge within the last 30 daysAdvanced ageAfrican American ethnicityUse of 5 concomitant medicationsShorr RI, et al. Arch Intern Med 1997; 157:1681-86.Zammitt NN, Frier BM. Diabetes Care 2005; 28:2948-61.
Hyperglycemia and Hypoglycemia in Older AdultsLongitudinal Trends in Hospital Admission forHyperglycemia and Hypoglycemia in Older AdultsLipska KJ, et al. JAMA Intern Med 2014;174:1116-24.
Hypoglycemia: Action Plan Severe or frequent hypoglycemia is an absoluteindication for the modification of treatment regimens,including setting higher glycemic goals Hypoglycemia unawareness or one or moreepisodes of severe hypoglycemia should triggerreevaluation of the treatment regimenDiabetes Care 2016;39:S1.
Diabetes may be Overtreated in Older AdultsAbout 25% of patients in the VA system have diabetesn 652,378 patients receiving insulin or sulfonylurea. The denominator population: patients 75 years or older;serum creatinine level, 2.0mg/dL; or diagnosis of cognitive impairment or dementia. A,B,C, outliers.Tseng CL, et al. JAMA Intern Med 2014;174:259-268. p.
Polypharmacy in Older Adults with Diabetes
PolypharmacyCommon Comorbidities Requiring DailyMultiple Drug RegimensCommon Comorbidities RequiringOccasional Multiple Drug RegimensHypertensionGlaucomaDyslipidemiaPeripheral vascular diseaseCoronary artery diseaseLower-extremity ulcersRenal diseaseObesityCongestive heart failureNeuropathyCognitive dysfunctionDepressionDiabetes Medications Oral agentsNon-insulin injectablesRapid-acting insulin analogsLong-acting analogsTraditional insulins
Polypharmacy four prescriptions associated with an increased risk offalls and increased fear of falling four prescriptions associated nine-fold risk of cognitiveimpairment among adult diabetes patients May be multiple prescribers – risk of duplicate therapiescan be high Increases risk of adverse effects, drug interactions,geriatric syndromes Increases risk of prescribing and dispensing errorsHaung ES, et al. J Gen Int Med 2010; 25(2):141-46.Fulton MM, Allen ER. J Am Acad Nurse Pract 2005;17:123-32.
Adverse Drug Reactions in Older Adults Approx. 100,000 hospitalizations for adverse drugevents per year among older adults ( 65)in US Antidiabetic agents accounted for one quarter ofadverse drug hospitalizations in older adults– Insulins, 14%– Oral hypoglycemic agents, 11% Adverse reactions generally resulted fromunintentional overdosesBudnitz DS, et al. N Engl J Med 2011; 365:2002-12.
Think-Pair-Share What are common comorbidities in the olderadult with diabetes? Which ones are associated with multipledrug regimens?
Case StudyIntroduction Mr. C is a 76-year-old retired lawyer; he has ahistory of hypertension and type 2 diabetes Physical exam: height, 5’9” (175 cm); weight,161 lbs (73 kg); BP, 138/72 mmHgContinued
Case Study (cont’d)Discussion questionWhat should Mr. C be screened for to provide a framework todetermine targets and therapeutic approaches?A. Cognitive impairmentB. DepressionC. Medical, mental, functional, and social geriatric domainsD. A and BE. A, B, and C
Diabetes Prevention ProgramLifestyle change 7% weight loss and maintenance 150 min/wk physical activity 60 years reduced risk 71% 10-year follow-up with continued lifestyle change:- 49% risk reduction vs. 34% for the total cohort- Reduction in urinary incontinence- Improvement in quality of life domains and cardiovascularrisk factorsKnowler WC, et al. Diabetes Prevention Program. Lancet 2009: 374;1677-86.Brown JS, et al. Diabetes Care 2006; 29:385-90.
Summary One out of every three to four individuals age 65 has diabetes Screening every 3 years in adults 45 and older, or annually for peoplewith prediabetes Diabetes Prevention Program is effective in reducing or delaying risk fortype 2 diabetes Goal directed therapy of glucose, BP, and lipids modified according to lifeexpectancy and or illness burden reduces risk for micro- andmacrovascular complications Choice of diabetes medications in older adults requires carefulassessment of hypoglycemia riskKirkman MS, et al. Diabetes Care 2012;35:2650-64.
Helpful Resources
Guidelines Full versionAbridged version for PCPsFree appPocket cards with key figuresFree webcast for continuingeducation creditProfessional.Diabetes.org/SOC
Professional Education Live programs Online self-assessmentprograms Online webcastsProfessional.Diabetes.org/CE
Diabetes Self-Management Education Find a recognized DiabetesSelf-Management program Become a recognizedDSME program Tools and resources forDSME programs Online education documentation toolsProfessional.Diabetes.org/ERP
Professional Membership Journals Meeting, book and journaldiscounts Career center Quarterly member newsletterProfessional.Diabetes.org/membership
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Older Adults 7.5% Reasonable A1C goal for healthy older adults 7% May be appropriate if it can be safely achieved in healthy older adults with few comorbidities and good functional status 8.5% Appropriate for older adults with multiple comorbidities, poor health, and limited life expectancyFile Size: 1MB
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