diabetes and the older patient where we’ve been, where we’re going…
TRANSCRIPT
Diabetes and The Older Patient
Where we’ve been, where we’re going…
Objectives
1. Review the treatment options in caring for older patients with diabetes
2. Understand the risks of hyperglycemia and hypoglycemia in older patients
3. Appreciate the importance of cardiovascular risk reduction in older patients with diabetes by treating hypertension and hyperlipidemia
4. Gain awareness of an association with diabetes, HTN, and vascular risk factors with dementia
5. Understand the complexities associated with “brittle” diabetes in frail older patients
Outline
Prevalence
Acute complications
Treatment options and goals
Tube feeding, type 1 diabetes, nursing home care
Risks of longstanding diabetes
Reducing cardiovascular events: treating hypertension and dyslipidemia
Dementia: association with cardiovascular risk factors; ?can we prevent it?
Cases
Case Study #1
78 y/o nursing home resident presents for evaluation of recurrent episodes of severe hypoglycemia. Diagnosed at age 65 on insurance exam. Treated with sulfonylurea without response for ~1 year. Subsequently treated with insulin. Currently treated with Novolog 70/30 14 units in the AM and Lantus 10 units at bedtime. Glucose logs reveal 4-6 readings per day ranging from 30’s to mid 500’s over the last 2 weeks. Severe hypo is usually during the afternoon or in the early AM. Average on meter 195 mg/dL with SD 130 mg/dL
PMH: None. FH: No early vascular disease. SH: No habits
PE: 61”, 98 lbs, 138/66, 82. Exam normal for age
A1c=8.6%; Creatinine=1.3, TC=150, HDL=70, LDL=70, TG=50
Case 1:
Does this patient have type 1 diabetes?
How would you treat this patient?
Case study #2
92 year old woman comes to you on glyburide at 10 mg a day. She, after much discusssion, is unable to check her own glucose. She is very afraid of having a hypoglycemic reaction as she lives alone. Her Hgb A1C is currently 9.8%. She is otherwise healthy, on no other medications, and is completely active and independent.
Case # 2
What is the goal of treatment in this woman?
What are the risks and the benefits of “tight” control for this patient?
What should her goal A1C be?
Describe some barriers to self monitoring for older patients.
Would metformin therapy be a consideration for this patient? What would be the risks?
Case study #3
An 88 year old woman with significant depression, HTN, chronic pain with spinal stenosis and a long history of an obsessive compulsive personality disorder is admitted to the hospital with confusion and dehydration. She takes insulin faithfully, and is found to have a glucose of 23 on admission. History reveals that she has been more depressed, and has lost 15 pounds which puts her now at 83 pounds…
Case #3…
Further history reveals that she has not been sleeping, and is wearing plastic gloves for fear of germs. Her HgbA1C is 6.1%, and she is very afraid of losing optimal control so has restricted her diet so that now she is eating only one bowl of rice a day. She divides this into three portions so she does not overwhelm her system with “carbs…”
Case # 3…
Describe her mental illness and how this is impacting upon care of her diabetes.
How should dietary restrictions be approached in the elderly, especially those who may be at baseline undernourished, underweight or at risk for missing meals?
Case # 4
You are following a 75 year old woman in the nursing home who has a severe dementia that is probably mixed alzheimers/vascular type, complicated by diabetes, hypertension and hyperlipidemia.
Case # 4…
How tight should control be for this patient? What would be an optimal HgbA1C?
What would be the potential benefits of treating her diabetes and hypertension more aggressively? What would be the risks?
Does the fact that she is in the nursing home setting make you more or less likely to treat her diabetes and hypertension aggressively?
Case # 5
A healthy, active, independent 85 year old woman with DM presents to you for care. She is concerned because her sister has a severe dementia. Other than a blood pressure of 150/70, her PE is unremarkable.
Case # 5
A healthy, active, independent 85 year old woman with DM presents to you for care. She is concerned because her sister has a severe dementia. Other than a blood pressure of 150/70, her PE is unremarkable.
Case study 5
Is her risk of dementia higher with an underlying diagnosis of diabetes?
What is the significance of isolated systolic hypertension in the elderly? Should this be treated?
What is the average life expectancy of a healthy 80 –85 year old woman?
Some Numbers…
Aging of America– Average life expectancy 72-79– At age 65, average life expectancy 82!– At age 85, average life expectancy 90– Fasting growing segment: over 85
1.5% population Almost 5% of population by 2050
Prevalence of Diabetes
Prevalence of Cardiovascular disease
Prevalence of Dementia
Some Numbers…
Aging of America
Prevalence of Diabetes– Over 10% those over 65– Framingham Data: Diabetes or impaired glucose tolerance
(fasting glucose 120-139) in nearly 40% those over 65
Prevalence of Cardiovascular Disease
Prevalence of Dementia
Some Numbers…
Aging of America Prevalence of Diabetes Prevalence of Cardiovascular Disease
– Heart disease and stroke: 1st and 3rd leading causes of death – 60% deaths in those over 85 due to CVD– Morbidity: stroke and CHF– Cardiovascular Health Study: new events over 10 years
Coronary Disease: 39.6/1000 person yrs for men, 22.3 for women Stroke: 14.7/1000 person years CHF: over 6% per year in those over 85
Prevalence of Dementia
Some Numbers…
Aging of America
Prevalence of Diabetes
Prevalence of Cardiovascular Disease
Prevalence of Dementia– 6-10% those over 65– 30-50% those over 85– Nearly 70% in those over 95– By 2025, expected to have 2 million centenarians in US!– Leading public health concern as the new chronic disease…
What are the risks of Diabetes in the older patient?
Number 1: Cardiovascular disease
Nephropathy– Increasing importance of ESRD in older patients
Neuropathy
Retinopathy
Problems with Feet
New directions:– Dementia– Marker of bad outcomes
Hyperglycemia bad predictor in those admitted with stroke… Hyperglycemia upon admission in patients with no prior hx of DM
associated with worse outcomes/higher mortality
Diabetes: Diagnosis
Same standards to diagnose– Fasting glucose over 140– Impaired glucose metabolism with fasting glucose
120-139 ? increased risk even in this group Longitudinal study of older patients: those with Impaired
Fasting Glucose had slightly increased risk of cognitive impairment and dementia compared to those with normal glucose, less risk than in those with diagnosis of DM
Hyperglycemia
Dehydration– Increased risk in elderly due to decreased intake and
decreased thirst mechanism– Can lead to falls, confusion
Visual disturbances– Significant hyperglycemia distorts lens leading to increased
blurring of vision
Confusion
Nonketotic Hyperglycemic Hyperosmolar Coma
More common than DKA in older patients
Higher mortality
Usually associated with severe dehydration, infection, myocardial event, stroke, acute stress
Precipitating factors: dementia, decreased access to fluid, decreased thirst mechanism
Hypoglycemia
Risk factors:– Older patients– Renal insufficiency
“normal” creatinine means less: glomerular filtration rate is NOT normal in 90 year old woman who weighs 85 lbs with creatinine of 1.1
– Long acting oral agents Especially in those with renal insufficiency
– Poor nutrition Decreased muscle mass and poor glycemic reserves
– Alcohol use– CHF– Post hospitalization– Polypharmacy
Treatment Options
Individualized
Weigh risks of hyperglycemia with hypoglycemia
No data that tight control prevents stroke or cardiovascular events or improves mortality in this age group
Consider cost of medications, limited coverage
Risk of “polypharmacy”, increased risk of side effects and drug-drug interactions
Treatment must be practical: are there functional limitations that will make plan of care difficult
Treatment Options
Overall same
Sulfonylureas
Metformin– Lactic acidosis: increased with renal insufficiency– ?contraindication in over 80– Contraindications: contrast dye, liver disease, ETOH, severe infection/acute
illness
Alpha-glucosidase inhibitors (acarbose)
Thiazolidinediones (rosiglitazone, pioglitazone)– Pro: can be used with renal insufficiency– Cons: costly, edema and volume overload
Insulin
May be best option Can the patient do it?
– Dementia– Caregiver– Vision– Arthritis
Likely underutilized due to fear of hypoglycemia…
Glargine (lantus) insulin
Long acting Often fear of hypoglycemia because long
acting, especially in patients with renal insufficiency or unreliable po intake
But studies demonstrating less risk of hypoglycemia, especially in patients with “brittle” diabetes and nocturnal hypoglycemia
Treatment Goals
Individualized No data for tight control… Most recommend Hgb A1c 7-8% Other options:
– Tight control: healthy “young” with likely long lifespan (20years) to decrease risk nephropathy, retinopathy
– “permissive”: those with advanced illnesses, terminal illnesses; goal more to prevent severe hyperglycemia and avoid hypoglycemia; goal glucoses 200 range
Some special circumstances
Tube feeding– Increases hyperglycemia– Specialized formulas– Acute setting: continuous insulin– Long term: basal insulin with glargine; with bolus feeds, consider
short acting insulin prior to bolus
Type 1 diabetes– More common in younger patients but can occur in older patients– DKA– “brittle” with episodes of hypoglycemia
Nursing home setting
Decreased prevalence in older residents (?5%) Risk of ulcers (heel and sacral) Risk of dehydration Little to support dietary restrictions in frail nursing home elders
– Quality of life concerns– Risk of malnutrition– Anorexia/depression– Chewing/dental problems– 2001 study found no difference in glycemic control in patients on
restricted diet compared to those on regular diet with more emphasis on pharmacologic control
Nephropathy
No recommendation to screen for microalbuminuria in patients with normal renal function
– Lower risk of ESRD in older patients with DM– Long interval between presence of albumin and ESRD, so
previously not considered in over 70 group
?whether this will change– Lifespan of 70 year old is 10 years or more– ESRD increasing prevalence in elderly with more older
patients on dialysis…– Marker of increased stroke and CVD risk in addition to
nephropathy in older patients
Vision…
Retinopathy– Prevalence in older patients with DM seems to be less and
overall less progressive disease than in younger patients with DM
Glaucoma– Three times more common in older patients with diabetes
(11% vs 3.8%)
Cataracts– More common in older patients with DM (38% vs 16%)– Association with more rapidly progressive posterior capsule
cataracts …
Neuropathy
Very common– Over 50% in those over 80
Not always due to Diabetes, often unknown cause
1/3 older patients cannot see/reach feet Importance of caregiver education
Treatment of the Frail
Care with any dietary restrictions
Significant number nursing home residents with weight loss, at risk for malnutrition
Tight control likely not goal
Still consider treatment of cardiovascular risk factors to reduce risk of CHF, stroke and morbidity
Nursing home setting may provide better monitoring, medication compliance
The Big Goal of Treatment: Prevention of Cardiovascular Events…
Hypertension
Hypertension is very common in older patients, mainly due to Isolated Systolic Hypertension (SH)
– Hypertension present in 60% those over 65– 75% hypertension in older patients due to SH– JNC definition: SBP >160, DBP <90– Pulse Pressure: SBP – DBP
Higher (over 50) due to stiff arteries in older patients
– SBP and PP MORE predictive of stroke and CV events in older patients
Hypertension
Multiple large randomized controlled trials have demonstrated significant benefit in treating Systolic Hypertension in older patients– SHEP– SYST-EUR– SYST-CHINA– SCOPE
Systolic Hypertension
Treatment of SH in older patients:
– Decreased risk of stroke
– Decreased risk of CHF
– Decreased combined endpoint of all CV events (CHF, stroke, CAD, mortality)
Treatment of Hypertension
Choice of agents:
– Thiazide diuretics (HCTZ, maxzide) Good news: ALLHAT study: JUST AS EFFECTIVE AS THE
MORE EXPENSIVE, NEWER MEDICATIONS!
– ACE inhibitors, angiotensin II receptor blockers, long acting calcium channel blockers
– Beta blockers in those with indication ( MI); some concern that may not be as effect as thiazides, ace inhibitors in prevention of CV events
Treatment of HTN
Orthostasis present in 30% people over age 75
Care to prevent orthostatic hypotension in older patients with treatment
Some concern that too much lowering of DBP (leading to increased Pulse Pressure) is associated with higher rates of CV events
– Treated patients still fared better than placebo
– Higher PP likely MARKER of bad outcomes (possibly associated with “stiffer” arteries), not necessarily the CAUSE of bad outcomes…
Systolic Hypertension and Dementia…
Epidemiological studies originally demonstrated associated between SH and dementia in older patients
Surprise finding in SH trials
– Patients in treatment arms of trials had reduced risk of dementia at follow up (4 years) compared to those in placebo group
– Two surprises: Those in placebo group, even after trial ended and started on
antihypertensive treatment, STILL had increased risk of dementia Risk of Vascular AND Alzheimer dementias were increased!
Dementia
Systolic Hypertension and Diabetes seem to be independent risk factors for dementia
– Not only vascular dementia, also associated with alzheimer type dementia
– SH, DM, and dementia all more common with aging: a difficult web to untangle…
– But dementia seems to be related to or worsened by traditional cardiovascular risk factors…
Treatment of SH: Summary
Treatment of SH in older patients decreases the risk of stroke, CHF, and combined CV events
Evidence that treatment of SH prevents dementia…
Aging and HTN as huge risk factors for CVD
Aging, HTN and DM HUGE risk for CVD
Treatment of CVD risk factors such as HTN critical treatment of older patients with DM
Thiazide diuretics cheap and effective in older patients
ACE inhibitors effective and studies show well tolerated with no impact on QOL
Hyperlipidemia
Previously many older patients not treated– Thought that statin agents took years to have effect, and that
those over age 70 would not see benefit– Often cited “lack of data” in older group – Worry about increased risks
But…– Newer evidence that statin agents work short term– Newer thoughts about average lifespans…– Lack of data due to prior studies excluding older patients, not
due to lack of observed benefit in trials…– So far, increased risks of rhabdo and liver disease have not
really panned out in older patients
Hyperlipidemia
More studies now addressing treatment of hyperlipidemia in older patients
CARE trial: diabetic patients with LDL <130 benefited from statin agents to further reduce cholesterol, regardless of age
Heart Protection Study: those over 75-80 had a GREATER reduction in cardiovascular events (29%) compared to the younger patients in the trial (25%)
Summary of studies…
Hyperlipidemia
Given fact that older patients have much higher risk of CV events, then the same relative risk reduction by treating this group will have overall GREATER absolute risk reduction
– If 5 % patients are at risk, and treatment reduces this by 50%, then 2.5% will have event, ARR of 2.5%
– If only 2% are at risk, RRR of 50% decreases the incidence to 1%, ARR of 1%
– If more patients are at risk, then more will benefit
– The greatest benefit can be seen in those who are the greatest risk!
Hyperlipidemia
Treatment groups:
– Older patients with DM
– Older patients with prior CV event (stroke, MI, CHF)
– All older patients with hyperlipidemia?
Burdon of asymptomatic atherosclerosis HIGH Patients over age 70 should be considered very likely to have
underlying CAD/CVD (much as those with diabetes): the new Cardiovascular equivalent
Treatment of Hyperlipidemia: summary
Aging considered the new “cardiovascular” equivalent
Aging and DM Huge risk factors for CVD
Treatment of hyperlipidemia in older patients is well tolerated
Treatment of hyperlipidemia in older patients has similar reductions in CV events as in younger
Given the increased risk in this group, the potential benefit is actually greater
Not clear mortality benefit: but any difference in stroke, CHF, CV events and even potentially dementia may mean more in this group than mortality!
Treating other CV risk factors in the older patient with DM
Smoking cessation Weight loss Dietary changes
– DASH: older patients in trial had benefit with decreased SBP with a diet low in Na and fats and rich in K
– TONE: older patients with mild SH were able to go off single agent when treated with low Na diet, weight loss or both
Exercise Daily ASA
Summary Points
Not clear that tight control of glucose is of great benefit in older patients
Diagnosis and treatment options are not really different
Avoidance of hypoglycemia and severe hyperglycemia are important
Care in older patients must include consideration of Functional Status
– Cognition– Physical ability (vision, arthritis)– Social support– Financial support
Summary Points…
DM and HTN are traditional risk factors for CVD
Aging as “cardiovascular equivalent”, older patients have HIGH likelihood of underlying CVD
Older patients with DM and HTN die of CVD and suffer morbidity from strokes and CHF
Dementia is probably related to underlying CV risk factors, with an increased prevalence in those who
– are older– Have diabetes– Have SH
Treatment of CV risk factors may decrease the risk of dementia
Summary
Where we have been– Not looking/not screening for diabetes in older patients– Assuming older patients do not have the life expectancy to
justify treatment of diabetes, htn, hyperlipidemia– Excluding older patients from trials – Emphasizing “start low and go slow”
Where we are– Including older patients in trials– Recognizing that older patients are living longer and better– Recognizing that prevention of CHF and stroke, even in
frail, is key
Summary:
Where we are going– Understanding diabetes in older patients need not
always be “type 2”; gaining further understanding of “brittle: diabetes in older patients
– Appreciating that CV disease as the leading cause of mortality and morbidity in the elderly
– Seeing DM, HTN and aging as high risk for CVD– Viewing age as a “cardiovascular equivalent”– Balancing risks of NOT treating with potential risks of
treatment– Looking at dementia as a disease modifiable or
preventable by treatment of traditional CV risk factors
Discussion of Cases…
Case 1
78 y/o nursing home resident presents for evaluation of recurrent episodes of severe hypoglycemia. Diagnosed at age 65. Currently treated with Novolog 70/30 14 units in the AM and Lantus 10 units at bedtime. Glucose logs reveal 4-6 readings per day ranging from 30’s to mid 500’s over the last 2 weeks. Severe hypo is usually during the afternoon or in the early AM. Average on meter 195 mg/dL
Case 1
Does this patient have type 1 diabetes?
How would you treat this patient?
Case 2
92 year old woman comes to you on glyburide at 10 mg a day. She is unable to check her own glucose and is very afraid of having a hypoglycemic reaction as she lives alone. Her Hgb A1C is currently 9.8%. She is otherwise healthy, on no other medications, and is completely active and independent.
Case 2
What is the goal of treatment in this woman?
What are the risks and the benefits of “tight” control for this patient?
What should her goal A1C be?
Describe some barriers to self monitoring for older patients.
Would metformin therapy be a consideration for this patient? What would be the risks?
Case 3
An 88 year old woman with significant depression, HTN, chronic pain with spinal stenosis and a long history of an obsessive compulsive personality disorder is admitted to the hospital with confusion and dehydration and hypoglycemia; she has been more depressed, and has lost 15 pounds which puts her now at 83 pounds…
Case 3
she has not been sleeping, and is wearing plastic gloves… Her HgbA1C is 6.1%, and she is very afraid of losing optimal control so has restricted her diet so that now she is eating only one bowl of rice a day. She divides this into three portions so she does not overwhelm her system with “carbs…”
Case 3
Describe her mental illness and how this is impacting upon care of her diabetes.
How should dietary restrictions be approached in the elderly, especially those who may be at baseline undernourished, underweight or at risk for missing meals?
Case 4
75 year old woman in the nursing home who has a severe dementia that is probably mixed alzheimers/vascular type, complicated by diabetes, hypertension and hyperlipidemia.
Case 4
How tight should control be for this patient? What would be an optimal HgbA1C?
What would be the potential benefits of treating her diabetes and hypertension more aggressively? What would be the risks?
Does the fact that she is in the nursing home setting make you more or less likely to treat her diabetes and hypertension aggressively?
Case 5
A healthy, active, independent 85 year old woman with DM presents to you for care. She is concerned because her sister has a severe dementia. Other than a blood pressure of 150/70, her PE is unremarkable.
Case 5
Is her risk of dementia higher with an underlying diagnosis of diabetes?
What is the significance of isolated systolic hypertension in the elderly? Should this be treated?
What is the average life expectancy of a healthy 80 –85 year old woman?