• 13% of adults older than 70 years have diabetes mellitus, and 11% remain undiagnosed

• diabetes mellitus increases the risk for development or worsening of many common geriatric syndromes.

General Guidelines

smoking cessation, treatment of hyperlipidemia with diet or medication (particularly statins), aspirin, aggressive treatment of blood pressure with use of angiotensin-converting enzyme (ACE) inhibitors or angiotensin-receptor blockers

Diabetes Mellitus and the Elderly

• Macrovascular and Microvascular Disease Hypertension, elevated lipid levels, and atherosclerotic

heart disease are the causes of most cases of macrovascular disease,

The most common cause of deathis ischemic heart disease, while neuropathy is the most common complication of microvascular disease.

Symptom Presentation of Diabetes Is Different in the Elderly

• Older adults with recent onset of diabetes do not present with the classic 3 Ps: polyphagia, polydipsia, and polyuria. These patients may only present with falls, urinary incontinence, fatigue, lethargy, weight loss, and decreased cognition.

Individualizing Treatment in Older Adults with Diabetes Mellitus

• The elderly population has varied comorbid conditions and broad differences in functional status. Drug-drug interactions are common in this group, and life expectancy varies. Polypharmacy is also a concern --

June M. McKoy, MD, MPH, JD   Mescape

Management of Hypertensive Patients With Diabetes Mellitus

• The prevalence of hypertension in patients with type 2 diabetes is about two times that observed in the general

• ACE inhibitors were the only agents proven to reduce the ESRD and death rates in patients with type 1 diabetes and renal . Atenolol had significant decline in creatinine clearance rate compared with those in the ACE-inhibitor and the nondihydropyridine calcium-channel blocker

• The nondihydropyridine calcium-channel blockers have been shown to protect the decline in creatinine clearance to the same extent as ACE inhibitors in patients with type 2 diabetes in a small

• Angiotensin II-receptor blockers (ARBs) are also able to reduce proteinuria in patients with diabetes.

Osteoarthritis

Osteoarthritis (OA) by definition is a failure of joint cartilage due to “wear and tear.” By age 75, nearly 85% of the U.S. population has clinical or radiographic features of OA

PATHOGENESIS Osteoarthritis develops when an imbalance between the biologic properties of these structures and joint loading exists. In osteoarthritic cartilage, decreases in the levels of glycosaminoglycans, keratan sulfate, and hyaluronic acid cause diminished aggregation of proteoglycans and impaired function of the cartilage structure. Cartilage oligomeric matrix proteins (COMP), which play a role in organization of collagen fibrils, can be detected in the serum of patients with OA at higher levels, suggesting disruption of normal cartilage metabolism in the affected population.

• CLINICAL MANIFESTATIONS

The typical presentation of OA is joint pain, Morning stiffness The affected joint can be tender on palpation, have crepitus, and usually mild-to-moderate swelling. Bony enlargement of distal interphalangeal joints (Heberden’s nodes) and proximal interphalangeal joints (Bouchard’s nodes) are common in idiopathic OA.

It is important to remember that older patients with OA may not be able to voice their complaints if significant cognitive impairment is present. Pain assessment tools developed for such patients include assessment of the breathing patterns, vocalization, facial expression, body language, and consolability

• TREATMENT

• Multiple trials have demonstrated that nonpharmacologic approaches to osteoarthritis treatment provide benefit beyond analgesics.

Physical therapy and exercise have proven beneficial in several randomized, use of heat and cold, Transcutaneous electrical nerve stimulation (TENS)

• Dietary supplements Framingham Study data suggested that intake of vitamin C of at least 152 mg per day, vitamin E, and beta-carotene may reduce the risk of OA progression, whereas low vitamin D intake increased risk of OA progression.

- Elena Dyer, MD, PhD, and Mitchell T. Heflin, MD . Medscape

Pharmacologic treatments

• Acetaminophen has been effective (dose 4 g/day) as ibuprofen (dose 2400 mg/day)

• Glucosamine and chondroitin compounds. • Nonsteroidal anti-inflammatory drugs (NSAIDs)• Nonselective NSAIDs46 and cyclooxygenase-2 (COX-2)

inhibitors47 • Opioids • Intra-articular injections of hyaluronic acid

Anemia in the Elderly

• Anemia is common in the elderly. The World Health Organization defines anemia as a “hemoglobin of less than 12 g/dL in women and less than 13 g/dL in men.” Using these criteria, the prevalence of anemia in men older than age 85 has been found to be as high as 44%.3,4

• Anemia can develop slowly, causing few symptoms or signs to appear until late in the course of illness. The symptoms of anemia that do develop, such as fatigue, weakness, and lack of stamina, can be erroneously attributed to aging.

• There are few symptoms specific for anemia in the elderly. Shortness of breath from significant anemia is impossible to separate from that of congestive heart failure (CHF) exacerbated by the anemia. Signs also may be overshadowed by those from disorders aggravated by the anemia, including worsening CHF, cognitive impairment, and apathy. Although conjunctival pallor has been shown to be a reliable sign of anemia, it is more difficult to detect in the already pale elderly.

Anemia of Chronic Disease The most common form of anemia in the elderly is that of

chronic disease. Many diseases, both chronic and acute, have anemia as part of the clinical picture, but making the determination that a particular older person’s anemia is caused by one of several coexisting chronic conditions can be difficult.

• Several mechanisms lead to anemia in chronic conditions. First, in anemia of chronic disease, iron present in the reticuloendothelial system is not made available for erythropoiesis. Another mechanism believed to contribute to anemia of chronic disease is a decrease in red cell survival;

Treatment • No specific treatment exists for the anemia of chronic disease—rather,• Erythropoietin has been shown to decrease the number of transfusions

required in critically ill patients and may help in the treatment of anemia of chronic

Iron Deficiency Anemia • Iron deficiency anemia, another common cause of anemia in the elderly,

more often results from chronic gastrointestinal (GI) blood loss rather than from inadequate intake or absorption of iron. The long list of GI conditions that lead to blood loss includes nonsteroidal anti-inflammatory gastritis, peptic ulcer disease, gastroesophageal reflux disease with esophagitis, colon cancer, and angiodysplasia. Less commonly, chronic blood loss from the genitourinary or pulmonary tract can also cause sufficient iron loss to cause anemia. Iron deficiency anemia classically causes microcytosis.

• The serum ferritin level is the most helpful and reliable test used to diagnose iron deficiency anemia.

Treatment • The two components of treating iron deficiency anemia are to eliminate or

control further GI blood loss and to replace the patient’s iron stores. The usual recommended oral dose of elemental iron is 50 to 100 mg three times a day. A 325-mg tablet of iron sulfate provides about 65 mg of elemental iron, whereas a 325-mg tablet of ferrous gluconate provides 38 mg of elemental iron.

Differentiating Anemia of Chronic Disease from Iron Deficiency Anemia • Although important to determine, it can be difficult to ascertain whether iron

deficiency anemia or anemia of chronic disease is causing an older person’s anemia.

• Serum ferritin, a measure of stored iron and an acute-phase reactant, is the most useful test, but it is not perfect.

Vitamin B12 Deficiency • Vitamin B12 (cobalamin) deficiency is the cause of anemia

in 5-10% of the elderly, • Vitamin B12 deficiency can be difficult to detect in the

elderly, as this population does not always show the typical symptoms and signs. Anemia is only present in about 60% of older patients found to be vitamin B12 deficient.

• Neurologic symptoms of vitamin B12 deficiency can be the only symptoms.

• when anemia from vitamin B12 deficiency is present, it is not always the classic macrocytic and megaloblastic anemia, but can be normocytic or even microcytic.

Causes • Vitamin B12 deficiency more often results from inadequate

intestinal absorption than from inadequate intake. Pernicious anemia is the classic example of inadequate intestinal absorption of vitamin B12.

Treatment • Vitamin B12 can be given parenterally or orally; however, oral

treatment with high doses of vitamin B12 is replacing parenteral replacement because of ease of use and

Folate Deficiency Anemia

• Unlike vitamin B12 deficiency, folate deficiency usually develops as a result of inadequate dietary intake.

• The body stores very little folate, that is, only enough to last four to six months.

• Folate deficiency anemia is usually macrocytic, but like vitamin B12 deficiency anemia, it can be normocytic.

• In folate deficiency, about 25% of anemia is normocytic• Serum homocysteine levels can help in the diagnosis of

folate deficiency.

• The Cardiovascular Health Study of older persons reported that approximately 60% of their overall population and 88% of those with known diabetes had cardiovascular disease. Treatment of the elderly should almost always be considered as secondary prevention because age is a major risk factor for atherosclerosis.

• Several large-scale randomized clinical trials have shown that treatment with statins or fibrates reduces all-cause mortality, major coronary events, and thrombotic stroke.

Coronary Heart Disease • CHD is a disorder disproportionately affecting the elderly.

Management • The use of lipid-lowering medications, particularly those statins which

require dose titration to achieve optimum LDL lowering

Lipid Management in Older Patients

Treatment of Osteoporosis

Osteoporosis is a potentially devastating disease. Although it is a well-recognized problem in postmenopausal women, its impact on men is less appreciated

In 2000, risedronate was approved for the same indication. Alendronate became the first treatment approved for use in idiopathic male osteoporosis, specifically to increase bone mass in men with osteoporosis. Most recently, alendronate was approved for a weekly 70-mg dosing regimen to increase bone mass in men with osteoporosis.

• Calcitonin • Risedronate

Malnutrition

• Undernutrition and decreased nutrient reserves are estimated to affect substantial numbers of elderly persons.

• Malnutrition may increase the risk for many problems commonly found in elderly persons, for example, decreased resistance to infection, poor wound healing and increased skin friability, osteopenia, anemia, certain cardiovascular diseases, cataracts, and age-associated macular degeneration. In older adults, undernutrition often precedes hospitalization.

• Gastrointestinal functions change minimally with normal aging. Gastric acid secretion is diminished in 10 to 15% of older adults. Loss of olfactory function and decline in taste threshold sensitivity may adversely affect the older adult’s nutritional status.

• Macronutrients • Calories Energy intake progressively decreases with age.

• Protein Daily protein requirements are difficult to establish. Young and middle-aged adults require approximately 0.8 g/kg. Protein requirements may increase slightly with age, to 1.0 to 1.25 g/kg in healthy elderly persons.

• Fat Fat calories should not exceed 30% of total daily calorie intake. It is not known if there are changes in fat requirements with aging.

• Water Dehydration is the most common fluid and electrolyte disturbance in older persons. Many diseases affecting the mental or physical capabilities of older adults reduce their access to fluids or their ability to recognize or express thirst.

• Vitamins The recommended dietary allowances (RDAs) Vitamin C and the B vitamins (including folic acid) can become deficient over weeks or months, but fat-soluble vitamins A, D, and E, as well as those like vitamin B12 with efficient enterohepatic circulation and stores, require longer periods of deprivation to become deficient.

• Vitamin B12 (cobalamin) Estimates of the prevalence of cobalamin deficiency in elderly persons range from 3 to 44%. Deficiency in elderly persons may be due to atrophic gastritis, Helicobacter pylori infection, or gastric and ileal surgery. Prolonged use of gastric antacids, H2-receptor antagonists, or proton pump inhibitors further decrease absorption and thus exacerbate the deficiency.

• Vitamin D Poor vitamin D intake is common in older adults as sunlight exposure and consumption of fortified dairy products are often inadequate. Poor intake of dairy products also contributes to decreased calcium intake. This combination of calcium and vitamin D deficiencies leads to poor bone health and increased fracture risk.

• Vitamins as Antioxidants The vitamins with substantial antioxidant properties are vitamins C and E, and the carotenoids, precursors to vitamin A.

• The antioxidant vitamins likely have additional protective effects unrelated to their antioxidant properties.

Johnson E. Malnutrition. Clinical Geriatrics 2001;1: Clinical Geriatrics - ISSN: 1070-1389 - Volume 09 - Issue 01 - January 2001

Diagnosis and Management of Overactive Bladder

• Overactive bladder (OAB) is defined as urinary urgency (a strong and sudden desire to void) and frequency (increased number of micturitions), with or without urge incontinence (loss of urine associated with urgency if involuntary contraction of the detrusor is not suppressed), in the absence of local pathological or metabolic factors that would account for these symptoms.

• OAB has a greater impact on social functioning and emotional role limitations than even congestive heart failure, and its impact on physical status is roughly equivalent.

• The risk of developing OAB increases with age. In persons over age 75, OAB prevalence ranges from 30 to 40%.

• Symptoms of OAB negatively affect the quality of interpersonal and sexual relationships, sexual interest, and frequency of sexual activity. OAB can also be associated with loss of sleep due to the need to urinate frequently during the night.

• Causes that are considered responsible for the development of OAB include

neurological disease/ injury; local bladder/urethral irritation; bladder outlet obstruction; medications; aging; and idiopathic causes.

Diagnosis • A practical approach to diagnosing OAB includes medical history, screening

questions, physical examination, and urinalysis. A thorough medical history reveals bladder control symptoms and identifies examinations or procedures that may have bearing on the patient’s present status. The physician should focus on medical, neurological, and genitourinary status; review voiding patterns and medication; and administer a mental status examination, if appropriate.

Physical therapy inhibits detrusor muscle contraction by voluntary contraction of PFMs at the same time as the urge to void and prevents sudden falls in urethral pressure.

• Pharmacotherapy

• Anticholinergic agents are the mainstay of treatment and are often combined with behavioral therapy and PFM exercises. Acetylcholine-induced stimulation of post-ganglionic muscarinic receptors on detrusor smooth muscle is involved in normal and involuntary bladder contractions. In addition to their antispasmodic effect on the bladder and diminishing the frequency of uninhibited contractions, anticholinergics can increase total bladder capacity and delay the initial urge to void. Antimuscarinic agents are therefore effective in the treatment of OAB.

• the anticholinergic agents-limiting adverse-effects profile such as dry mouth, constipation, and blurred vision, include oxybutynin and tolerodine.

• Tolterodine was approved by the FDA in March 1998. This is a muscarinic receptor antagonist with higher specificity for the M2 receptors, and it helps improve frequency, urgency, and urge incontinence.

Treatment of Obesity in the Elderly Patient

• Obesity is a worldwide health concern, Reports from the National Institutes of Health (NIH) state over 50% of Americans are either overweight or obese. More specifically, it has been reported that of those 70 years or older, 37% are classified as overweight and another 15% are categorized as obese.

• secondary comorbidities associated with obesity: hypertension, heart disease, type 2 diabetes mellitus, dyslipidemia, stroke, gallbladder disease, osteoarthritis, sleep apnea, and breast, prostate, endometrium, and colon

ETIOLOGY • Obesity can occur when aging adults fail to decrease their caloric

intake to correspond with their decreased caloric expenditure.

• Another less-proven theory states obesity in the elderly may also be caused by impairment between the feedback mechanism of leptin levels and appetite regulation. Leptin is a hormone released from adipocytes.

DIET • Complying with a healthy hypocaloric diet and behavioral

modifications are the first steps toward weight reduction. Reducing caloric intake by 500 calories per day will usually result in a gradual but steady weight loss (1-2 pounds/week). Patients should limit their daily fat intake to less than 30% of their total calories with no more than 10% from saturated fat sources. Elderly persons should maintain their protein intake at approximately 15-20% of their total daily calories to prevent further muscle loss.

EXERCISE • Exercise is an important component of a successful weight reduction

program and should be a lifetime activity for all physically able

PHARMACOLOGIC THERAPY • According to obesity guidelines, obese patients should attempt to lose

10% of their body weight within six months through behavioral therapy, diet, and exercise. If this goal is not met, the addition of a pharmacologic agent may be indicated, especially for those with existing comorbidities, such as hypertension, diabetes, and dyslipidemia. The benefits of drug therapy have been demonstrated in young and middle-aged adults.However, data involving the elderly are very limited. Clinicians must also remember that weight loss medications can induce unwanted adverse effects and drug interactions, which may be problematic for much of the aged population.

• Clinical Geriatrics - ISSN: 1070-1389 - Volume 10 - Issue 07 - July 2002