Diabetes in Elderly Adults Diabetes in Elderly Adults

Diabetes in Elderly Adults Diabetes in Elderly Adults

• By the age of 75, approximately 20% By the age of 75, approximately 20% of the population are afflicted with of the population are afflicted with this illness.. this illness..

• obese older patients have resistance obese older patients have resistance to insulin-mediated glucose disposal .to insulin-mediated glucose disposal .

• delayed gastric emptying or delayed gastric emptying or gastroparesis is frequently reported gastroparesis is frequently reported for older adults with diabetes. for older adults with diabetes.

• Lean older patients with type 2 Lean older patients with type 2 diabetes had a marked impairment in diabetes had a marked impairment in glucose-reduced insulin secretion . It glucose-reduced insulin secretion . It has recently been suggested that thin has recently been suggested that thin elderly diabetics have a syndrome elderly diabetics have a syndrome intermediate between type 1 and 2 intermediate between type 1 and 2 diabetes, which might properly be diabetes, which might properly be thought of as type 1 1/2 diabetes. thought of as type 1 1/2 diabetes.

• 50% older persons with diabetes are 50% older persons with diabetes are unaware unaware theythey have the illness, have the illness, suggesting that symptoms of suggesting that symptoms of hyperglycemia are rarely present in hyperglycemia are rarely present in this patient population.this patient population.

• This may be because the This may be because the renal renal threshold for glucose increases with threshold for glucose increases with ageage, so that no sugar is spilled into the , so that no sugar is spilled into the urine until the glucose level is urine until the glucose level is markedly elevated. In addition, markedly elevated. In addition, because thirst is impaired with normal because thirst is impaired with normal aging, polydipsia is unlikely in elderly aging, polydipsia is unlikely in elderly patients with diabetespatients with diabetes, even if they are , even if they are hyperosmolar as a result of marked hyperosmolar as a result of marked hyperglycemia. hyperglycemia.

• Often, diabetes presents for Often, diabetes presents for the first the first time time in an elderly person who is in an elderly person who is hospitalized hospitalized with a complication with a complication that that may be related to diabetes, such as a may be related to diabetes, such as a myocardial infarction or a stroke. In myocardial infarction or a stroke. In frail elderly nursing home patients, frail elderly nursing home patients, nonketotic hyperosmolar coma may nonketotic hyperosmolar coma may be the first sign of diabetesbe the first sign of diabetes. .

• The goals of DM care in older adults, The goals of DM care in older adults, as in younger persons,as in younger persons,

• include include control of hyperglycemia control of hyperglycemia and and its symptoms; prevention, evaluation, its symptoms; prevention, evaluation, and treatment of and treatment of macrovascular and macrovascular and microvascular complications microvascular complications of DM; of DM; DM self-management through DM self-management through education; and maintenance or education; and maintenance or improvement of general health status. improvement of general health status.

• • Chronically ill, institutionalized patients with a short life Chronically ill, institutionalized patients with a short life expectancy do not require aggressive glucose control, but do expectancy do not require aggressive glucose control, but do require adequate control to facilitate healing and prevent: require adequate control to facilitate healing and prevent:

o Dehydration o Dehydration

o Symptoms of hyperglycemia or hypoglycemia o Symptoms of hyperglycemia or hypoglycemia

o Weight loss o Weight loss

Polypharmacy:Polypharmacy:

• Older adults with DM are at risk for drug Older adults with DM are at risk for drug side effects and drug-drug and drug-side effects and drug-drug and drug-disease interactions. Polypharmacy is a disease interactions. Polypharmacy is a major problem for older adults with DM, major problem for older adults with DM, who may require several medications to who may require several medications to manage glycemia, hyperlipidemia, manage glycemia, hyperlipidemia, hypertension, and other associated hypertension, and other associated conditions. conditions.

Older adults tend to have less muscle than Older adults tend to have less muscle than younger people and generally have a younger people and generally have a higher percentage of body fat. The higher percentage of body fat. The elderly are generally less hydrated than elderly are generally less hydrated than younger individuals and thus tend to younger individuals and thus tend to have less total body water .Blood flow to have less total body water .Blood flow to organs such as the kidneys and liver is organs such as the kidneys and liver is diminished with age, which can lead to diminished with age, which can lead to decreased metabolism and elimination of decreased metabolism and elimination of many drugs.many drugs.

Polypharmacy:Polypharmacy:

• Clinicians should perform a careful Clinicians should perform a careful review of each medication currently review of each medication currently being used by the patient during the being used by the patient during the initial visit and at each subsequent initial visit and at each subsequent visit and document whether the visit and document whether the patient is taking each medication patient is taking each medication properly. properly.

Urinary Incontinence:Urinary Incontinence:

• The older adult who has DM should be The older adult who has DM should be evaluated for symptoms of urinary evaluated for symptoms of urinary incontinence during annual screening. incontinence during annual screening.

women with DM are at higher risk than the general population for urinary incontinence.

• The risk factors for urinary incontinence The risk factors for urinary incontinence that are more common in older adults that are more common in older adults with DM include polyuria, overflow with DM include polyuria, overflow secondary to neurogenic bladder and secondary to neurogenic bladder and autonomic insufficiency, urinary tract autonomic insufficiency, urinary tract infection, candida vaginitis, and fecal infection, candida vaginitis, and fecal impaction due to autonomic impaction due to autonomic insufficiency. Urinary incontinence is insufficiency. Urinary incontinence is commonly unreported by patients and commonly unreported by patients and undetected by providers.undetected by providers.

Glycemic Control:Glycemic Control:

• For older persons, target hemoglobin A1c For older persons, target hemoglobin A1c (A1C) should be individualized. A (A1C) should be individualized. A reasonable goal for A1C in relatively healthy reasonable goal for A1C in relatively healthy adults with good functional status is 7% or adults with good functional status is 7% or lower. For frail older adults, persons with life lower. For frail older adults, persons with life expectancy of less than 5 years, and others expectancy of less than 5 years, and others in whom the risks of intensive glycemic in whom the risks of intensive glycemic control appear to outweigh the benefits, a control appear to outweigh the benefits, a less stringent target such as 8% is less stringent target such as 8% is appropriate. appropriate.

• • Chronically ill, institutionalized patients with a Chronically ill, institutionalized patients with a short life expectancy do not require aggressive short life expectancy do not require aggressive glucose control, but do require adequate glucose control, but do require adequate control to facilitate healing and prevent: control to facilitate healing and prevent:

o Dehydration o Dehydration

o Symptoms of hyperglycemia or hypoglycemia o Symptoms of hyperglycemia or hypoglycemia

o Weight loss o Weight loss

Monitoring: Monitoring:

• For the older adult with DM, a schedule For the older adult with DM, a schedule for self-monitoring of blood glucose for self-monitoring of blood glucose should be considered, depending on should be considered, depending on the individual's functional and the individual's functional and cognitive abilities. The schedule should cognitive abilities. The schedule should be based on the goals of care, target be based on the goals of care, target A1C levels, the potential for modifying A1C levels, the potential for modifying therapy, and the individual's risk for therapy, and the individual's risk for hypoglycemia. hypoglycemia.

.Some older adults may not be able to perform SMBG due to physical or cognitive impairment. In such situations, the glycemic goals may need to be adjusted to keep blood glucose levels higher, and the regimen should be simplified to avoid hypoglycemia for those at risk.

• “• “Start low and go slow” with all Start low and go slow” with all medications medications

• • Consider drug-drug interactions carefully Consider drug-drug interactions carefully as most older adult patients are on as most older adult patients are on multiple drugs as well as supplements. multiple drugs as well as supplements.

• • Do not assume that because the creatinine is normal Do not assume that because the creatinine is normal that kidney function is normal, since an older adult that kidney function is normal, since an older adult with decreased muscle mass can have normal with decreased muscle mass can have normal creatinine levels with significant renal dysfunction as creatinine levels with significant renal dysfunction as seen by low glomerular filtration rate (GFR). seen by low glomerular filtration rate (GFR).

• • Monitor liver and kidney function tests periodically Monitor liver and kidney function tests periodically even though diabetes medications, alone or in even though diabetes medications, alone or in combination, are safe in older adult patients when combination, are safe in older adult patients when selected carefully. selected carefully.

• In general, a creatinine clearance In general, a creatinine clearance estimated at < 60 ml/min warrants estimated at < 60 ml/min warrants dose adjustments of most renally dose adjustments of most renally cleared medications. In an older cleared medications. In an older woman (68 years) weighing 60 Kg with woman (68 years) weighing 60 Kg with a serum creatinine of 1.0, this would a serum creatinine of 1.0, this would translate to an estimated creatinine translate to an estimated creatinine clearance of 51 ml/min, just under this clearance of 51 ml/min, just under this threshold. threshold.

Medications:Medications:

• • Sulfonylureas:Sulfonylureas:

o Use with caution in older adult patients because of the risk of hypoglycemia.

o Avoid agents like chlorpropamide and glyburide because of their prolonged length of action.

o Shorter acting agents like glipizide, or the non-sulfonylurea insulin secretagogues repaglinide and nateglinide, can be useful to avoid nocturnal hypoglycemia, or to avoid hypoglycemia in patients with erratic oral intake.

• • Metformin Metformin

• o Use with caution in the older adult with diabetes because of an o Use with caution in the older adult with diabetes because of an increased risk of lactic acidosis in patients with impaired renal function. increased risk of lactic acidosis in patients with impaired renal function.

• o Measure serum creatinine and liver function tests (LFTs) periodically o Measure serum creatinine and liver function tests (LFTs) periodically in the older individual who receives metformin, and with any increase in the older individual who receives metformin, and with any increase in dose. in dose.

• o Measure creatinine clearance with a timed urine collection at least o Measure creatinine clearance with a timed urine collection at least annually and with increases in dosage of metformin in frail older adults, annually and with increases in dosage of metformin in frail older adults, or those with decreased muscle mass. or those with decreased muscle mass.

• o Avoid initiating in patients ≥ 80 years of age unless creatinine o Avoid initiating in patients ≥ 80 years of age unless creatinine clearance is within normal limits. clearance is within normal limits.

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• • Thiazolidinediones (TZDs Thiazolidinediones (TZDs

o TZDs are well tolerated by older adults as they do o TZDs are well tolerated by older adults as they do not cause hypoglycemia. Side effects of fluid not cause hypoglycemia. Side effects of fluid retention and leg edema can be limiting factors in retention and leg edema can be limiting factors in using this class of medications in the older adult. using this class of medications in the older adult.

o TZDs should be avoided in patients with Class III o TZDs should be avoided in patients with Class III and Class IV congestive heart failure. and Class IV congestive heart failure.

• • Alpha-Glucosidase Inhibitors: Alpha-Glucosidase Inhibitors:

o Alpha-glucosidase inhibitors are less effective than o Alpha-glucosidase inhibitors are less effective than other agents and may cause gastrointestinal side other agents and may cause gastrointestinal side effects. effects.

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• • Insulin: Insulin:

• Elderly subjects often make errors Elderly subjects often make errors when trying to mix insulin on their when trying to mix insulin on their own. The accuracy of insulin own. The accuracy of insulin injections has been shown to be injections has been shown to be improved in older patients when they improved in older patients when they are treated with premixed insulin.are treated with premixed insulin.

• In these situations, it is beneficial to use In these situations, it is beneficial to use simpler insulin regimens with fewer daily simpler insulin regimens with fewer daily injections, such as pre-mixed insulin injections, such as pre-mixed insulin preparations, pre-measured doses, and preparations, pre-measured doses, and easier injection systems (e.g., insulin easier injection systems (e.g., insulin pens with easy to set dosages). pens with easy to set dosages).

• Recommend equipment that is easy to hold, easy to read and requires the least amount of steps. Insulin pens and pre-filled syringes may be easier for older patients to use than a syringe. Syringe magnifiers are available if vision is a problem.

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Hypoglycemia: Hypoglycemia:

• • Older adult patients commonly exhibit Older adult patients commonly exhibit neuroglycopenic manifestations of hypoglycemia neuroglycopenic manifestations of hypoglycemia that include confusion, that include confusion,

delirium, dizziness, weakness or falls as delirium, dizziness, weakness or falls as compared to adrenergic symptoms. It is compared to adrenergic symptoms. It is important that older adult patients and their important that older adult patients and their caregivers recognize these symptoms as caregivers recognize these symptoms as hypoglycemia and treat appropriately.hypoglycemia and treat appropriately.

• • Frail older adult patients may have poor Frail older adult patients may have poor outcomes from even mild hypoglycemia. For outcomes from even mild hypoglycemia. For example, injurious falls can lead to unintended example, injurious falls can lead to unintended consequences such as institutionalization. In consequences such as institutionalization. In addition, hypoglycemia can exacerbate existing addition, hypoglycemia can exacerbate existing conditions (e.g., coronary artery disease or conditions (e.g., coronary artery disease or cerebrovascular disease). cerebrovascular disease).

• The older adult with DM who is on an The older adult with DM who is on an ACE inhibitor or ARB should have ACE inhibitor or ARB should have renal function and serum potassium renal function and serum potassium levels monitored within 1 to 2 weeks levels monitored within 1 to 2 weeks of initiation of therapy, with each of initiation of therapy, with each dose increase, and at least yearly. dose increase, and at least yearly.

• The older adult with DM who is The older adult with DM who is prescribed a thiazide or loop diuretic prescribed a thiazide or loop diuretic should have electrolytes checked should have electrolytes checked within 1 to 2 weeks of initiation of within 1 to 2 weeks of initiation of therapy or of an increase in dosage therapy or of an increase in dosage and at least yearly. and at least yearly.

Management of Management of Hyperlipidemia Hyperlipidemia

• • The targets of therapy, interval of lipid profile screening, and choice The targets of therapy, interval of lipid profile screening, and choice of medications for treatment of hyperlipidemia in older adult of medications for treatment of hyperlipidemia in older adult patients with diabetes are the same as those in younger adults. patients with diabetes are the same as those in younger adults.

• • When an individual does not have evidence of CVD and has a life When an individual does not have evidence of CVD and has a life expectancy that is determined by the provider to be three years or expectancy that is determined by the provider to be three years or less, relaxation of the goals of therapy may be made. less, relaxation of the goals of therapy may be made.

Eye and Foot Care: Eye and Foot Care:

• • Recommendations for eye and foot Recommendations for eye and foot examinations and treatment in older examinations and treatment in older adults with diabetes are the same adults with diabetes are the same as those for younger individuals. as those for younger individuals. Older adults may require additional Older adults may require additional education and devices such as education and devices such as mirrors to examine their feet due to mirrors to examine their feet due to decreased mobility and dexterity. decreased mobility and dexterity.

Nutrition: Nutrition:

• • The current trend is to distribute the The current trend is to distribute the patient’s carbohydrate intake as evenly as patient’s carbohydrate intake as evenly as possible throughout the day. Education possible throughout the day. Education regarding the importance of consistency in regarding the importance of consistency in carbohydrate intake and the timing of meals carbohydrate intake and the timing of meals can help avoid large fluctuations in blood can help avoid large fluctuations in blood glucose levels. glucose levels.

• • Every effort should be made to minimize the Every effort should be made to minimize the complexity of meal planning and to engage the complexity of meal planning and to engage the spouse, or others living with the patient, in creating a spouse, or others living with the patient, in creating a home environment that supports positive lifestyle home environment that supports positive lifestyle change. change.

• • In chronic care settings, there is no need for a rigid In chronic care settings, there is no need for a rigid and restrictive meal plan. A regular diet with and restrictive meal plan. A regular diet with consistent, moderate carbohydrate intake may be consistent, moderate carbohydrate intake may be sufficient and may help to avoid under nutrition. sufficient and may help to avoid under nutrition.

Physical Activity: Physical Activity:

• • Types of physical activities that may be appropriate Types of physical activities that may be appropriate for the older adult include: for the older adult include:

o Walking o Walking

o Swimming or water aerobics o Swimming or water aerobics

o Bicycle riding o Bicycle riding

o Yoga o Yoga

o Gardening o Gardening

o Household chores o Household chores