Mehdi ebrahimi

MD. Assistance professor of

endocrinology

Agenda:

1) Epidemiology of senile diabetes:

2) Pathogenesis of DM in older adult :

3) Clinical presentation:

4) Screening and diagnosis

5)Recommendations for treatment

Epidemiology

Diabetes mellitus is a group of metabolic

disorders characterized by hyperglycemia

due to :

abnormalities in insulin secretion

Insulin action

or both

Type 2 diabetes mellitus (DM) is an

epidemic that continues to increase rapidly,

affecting millions of people worldwide

It is one of the most common chronic

diseases affecting older adults

population is aging and rate of obesity are

increasing among middle-aged adults ,

people ≥65 years old will constitute the

majority of diabetic adults in the coming

decades.

Prevalence DM in 65 to 75 y subjects is

approximately 15-20%

Prevalence DM in subjects older than 80

y is 40%

Nearly half of people with DM

are

≥65 years old.

Baillikre's Clinical Endocrinology and Metabolism-- 389Vol.

11, No. 2, July 1997

ADA classifies DM affecting older adults in to

three types :

A) Type 1 : is the result of an absolute deficiency in insulin secretion

due to autoimmune destruction of the ß cells of the

pancreas.

B) Type 2 : is most commonly due to tissue resistance to insulin

action and relative insulin deficiency.

C) Secondary DM: injuries to the exocrine pancreas ; endocrinopathies characterized

by excesses of hormones , such as growth hormone , cortical ,

glucagon , and epinephrine, which antagonize insulin action ; drug

Diabetes mellitus, results in:

-decreased life expectancy -numerous complications and co morbidities -higher risk of other common geriatric conditions

1) polypharmacy 2) urinary incontinence 3) falls 4) cognitive impairment 5) depression 6)chronic pain

Older adults with diabetes can expect :

10- years reduction in life expectancy

mortality rate nearly twice that of people

without disease.

In older adults with diabetes:

The rates of myocardial infarction , stroke , and kidney failure are increased approximately 2-fold .

The risk of blindness is increased approximately 40%,

Most patients ≥65 years old who require dialysis have diabetes.

Mobility problems are about 2 to 3 time more

likely in older adults

older patients are frequently on multiple

medications, increased risk of drug

interactions with greater risk of adverse

effects, most commonly hypoglycemia .

Thus, management of DM in the elderly is

challenging and requires multi-dimensional

approach focusing on:

preventing diabetic complications,

early interventions for vascular disease,

and disability assessment.

Because of the heterogeneity in the older population , treatment goals must be carefully individualized

Pathogenesis of DM in

older adult :

The prevalence of both type 2 diabetes and

glucose intolerance increases with age the

reasons for this are not fully known.

there appears to be an interaction among

several factors , including:

1)Obesity contribute to impairments in insulin action.

2)decline in pancreatic ß-cell function and in the insulin-signaling mechanism

3)Changes in body composition such as increased visceral fat leading to insulin resistance .

4)Decreased level of physical activity

5)An altered inflammatory environment with aging

6) Some medications commonly taken by older adults

-diuretics , sympathomimetics, Glucocorticoids , niacin , and olanzapine-change carbohydrate

metabolism and increase glucose concentration.

Signs and Symptoms

elderly diabetics may not present with

classical symptoms which makes diagnosis

more difficult.

Polyuria may be seen as incontinence or

prostate problems.

Glucosuria may be missing due to chronic

renal disease.

glycosuria may be absent because the renal

threshold for glucose also increases with age

presenting symptoms may be

Dehydration,

confusion,

urinary incontinence,

urinary tract infections,

slow wound healing in the legs and feet,

complications related to DM

functional disability

Diabetic patients tend to have an accelerated ageing process that places them at greater risk of developing frailty at an earlier age

Frailty is characterized by:

deterioration in muscle and nerve function,

anemia,

declining cardiopulmonary reserve,

loss of executive function

The Cardiovascular Health Study showed:

25% of frail subjects were diabetic,

18.2% of pre-frail subjects were diabetic,

only 12% of non-frail subjects were diabetic.

It is clear that diabetes and frailty are closely interrelated, but only minimal evidence suggests the causal relationship between DM and frailty.

Aside from diagnostic challenges, elderly diabetic patients also more commonly have:

functional disabilities, cognitive decline, increased rates of bone fracture, increased hypoglycemic events

which all contribute to the complexity of diabetes care in the elderly population.

Screening and diagnosis

Clinical presentation of diabetes in old age is often asymptomatic and non-specific and clinical diagnosismay be delayed.

screening for and diagnosis of diabetes in older subjects:

should be in accordance with published international/national guidelines and no age modified criteria are currently recognised.

Plasma Glucose Level (mg/dL)

* Third criterion: casual plasma glucose 200 mg/dL (regardless of time since last meal) plus

classic symptoms of diabetes (polyuria, polydipsia, unexplained weight loss)

Stage of

Glycemic Control

Fasting Plasma

Glucose

OGTT

(2-hr Post-load Glucose)

<100

100 –125

126

<140

140 –199

200

Normal

IFGor

IGT

Diabetes*

ADA. Diabetes Care. 2007; 30:S5

Criteria for the Diagnosis of

Diabetes: 2007 ADA Guidelines

29

IFG = FPG 100 mg/dl (5.6 mmol/l) to 125

mg/dl (6.9 mmol/l)

IGT = 2-h plasma glucose 140 mg/dl ( 7.8

mmol/l) to 199 mg/dl (11.0 mmol/l)

Pre-diabetes

ADA. Diabetes Care. 2007; 30:S5

30

Glucose Tolerance Categories

FPG

126 mg/dL

100 mg/dL

7.0 mmol/L

5.6 mmol/L

Impaired Fasting

Glucose

Normal

2-Hour PG on OGTT

200 mg/dL

140 mg/dL

11.1 mmol/L

7.8 mmol/L

Diabetes Mellitus

Impaired Glucose

Tolerance

Normal

Diabetes Mellitus

ADA; Diagnosis and Classification of Diabetes Mellitus. Diabetes Care. 2007; 30:S4531

The prevalence and incidence rates of diabetes mellitus in elderly subjects (> 65 years) may be underestimated when using only fasting plasma glucose.

presence of isolated post-challenge hyperglycaemia (IPH) is common in older subjects and should alert the clinician to screen for cardiovascular disease

In high-risk older subjects with a normal fasting glucose:

1)OGTT 2)IF OGTT is not feasible,HbA1c

may be helpful in the diagnosis of diabetes.

A value of HbA1c > 6.5% may indicate the likely presence of diabetes.

Prevention and lifestyle change

1. In older adults with IGT regular exercise reduce the risks of developing type 2 diabetes independently of BMI.

2. Lifestyle intervention is preferable to metformin in reducing the risks of type 2

Recommendations for

treatment

A)Glucose regulation Targets

1. For older patients with type 2 diabetes, with single system involvement (free of other major co-morbidities)

HbA1c range of 7-7.5% should be aimed

FBS range of 90 -130mg/dl can be regarded as indicating good control.

2. For frail (dependent; multisystem disease; care home residency including those with dementia)

and patients high risk for hypoglycaemia

target HbA1c range should be 7.6-8.5%.

FBS range of 100-180mg/dl can be regarded as indicating good control.

B)Use of oral agents

1) In non-obese older people with diabetes in whom target levels of glucose or HbA1c have failed to be maintained on dietary/lifestyle first line therapy with

an insulin secretagogue or metformin should be offered.

2. Metformin should normally be first line therapy for older adults

3. An insulin secretagogue may be used in combination with metformin where glycaemictargets have not been achieved

Age per se is not a contraindication to the use ofMetformin

use is contraindicated in those with :

renal impairment (serum creatinine>130 μ/litre), severe coronary, cerebrovascular disease peripheral vascular disease

4) Glibenclamide should be avoided for newly diagnosed type 2 diabetes in older adults (>70 years)

because of the marked risk of hypoglycaemia.

Regularly assess patients for hypoglycemia, as

hypoglycemia risk is linked more to treatment

strategies than to achieved lower A1C.

Strongly consider changing therapy and/or

targets in presence of recurrent or severe

hypoglycemia

Use of insulin

When oral agents fail to lower glucose levels adequately, insulin may be given either as monotherapy or in combinationwith a sulphonylurea or metformin.

In older adults with diabetes, the use of pre-mixed insulin and pre-fi lled insulin pens

lead to a reduction in dosage errors and an improvement in glycaemic control.

Use of a glargine, determir rather than NPH-insulin should be considered in older patients who:

require the assistance of a carer, those residing within a care home, higher risk of hypoglycaemia.

B) Blood pressure regulation

Blood pressure should be measured at

every routine visit.

Patients found to have elevated blood

pressure should have blood pressure

confirmed on a separate day.

1. The threshold for treatment of high blood

pressure in older subjects with type 2 DM

140/80 mmHg or higher

Patients with confirmed blood pressure

should, in addition to lifestyle therapy, have

prompt initiation of pharmacological therapy to

achieve blood pressure goals.

2. In non-frail subjects with diabetes

older than 80 years:

an acceptable blood pressure on

treatment is :

a systolic of 140-145 mmHg,

a diastolic less than 90 mmHg.

3. For frail patients : (dependent; multisystem disease; care home residency including

those with dementia)

where avoidance of heart failure and stroke

may be of greater importance than

microvascular disease,

acceptable blood pressure is <150/90

mmHg.

4. In older patients with a sustained blood

pressure ≥140/80 mmHg and in whom

diabetic renal disease is absent:

first-line therapies include:

use of ACE inhibitors,

angiotensin II receptor antagonists,

long-acting calcium channel blockers,

beta blockers

thiazide diuretics.

5. In older patients with a sustained blood

pressure ≥140/80 mmHg with microalbuminuria

or proteinuria, treatment with:

ACE inhibitor or angiotensin II receptor

antagonist is recommended.

• As part of the assessment of older newly-

diagnosed HTN:

investigations to exclude secondary causes

must also be considered

There is less evidence for lipid-lowering

and aspirin therapy,

benefits of these interventions for primary and

secondary prevention are likely to apply to

older adults whose life expectancies is high.

C) Plasma lipid regulation

Recommendations for care

home diabetes

In view of the high rate of undiagnosed

diabetes in care home residents

at the time of admission to a care home

each resident requires to be screened for

the presence of diabetes.

Good clinical practice in care homes

Each resident should have an annual screen for diabetes

Each resident with diabetes should have an individualised diabetes

care plan with the following minimum details: dietary plan, medication

list, glycaemic targets, weight, and nursing plan.

Each care home with diabetes residents should have an agreed Diabetes

Care Policy or Protocol which is regularly audited.

All residents with diabetes require a risk-benefi t analysis in terms of

medication used, metabolic targets agreed, and extent of investigation

of diabetes-related complications.

Residents on insulin secretagogues and/or

insulin must be regularly reviewed for the

presence of hypoglycaemic symptoms

Optimal blood pressure and blood glucose

regulation may help to :

maintain cognitive and physical performance

for each resident with diabetes.

Recommendations in special

categories

a) Falls and immobility

1. As part of their functional evaluation at

diagnosis and at annual review,

older people with diabetes should

have a falls risk assessment.

This will include identifying risk factors which

can be minimised, e.g. certain medications, environmental items, and undertaking

measures of gait and balancee.

It is particularly important to monitor insulin

therapy,

where insulin secretagogues are used in a

patient with other risk factors for falls, an agent

with a lower risk of hypoglycaemia

should be substituted

Tight glycaemic control (HbA1c<7.0%)

must be avoided in older patients with type

2 diabetes who are at increased risk

of falling.

a) Cognitive impairment and low

mood states

1. At the diagnosis and at regular intervals

thereafter, patients 70 y and over

should be screened for the presence

of cognitive impairment

using an age- and language-validated

screening tool such as the MiniMental State Examination score.

2. Regular screening for cognitive impairment

and mood disorder is recommended

for residents with diabetes who are

at high risk of undetected disease.

3. Optimal glucose control may help to maintain

cognitive function in older people with diabetes.

4. Optimal blood pressure control help to

maintain cognitive performance and improve

learning and memory.

5. Prevention of repeated hypoglycaemia in

older patients with diabetes :

decrease the risk of developing cognitive

impairment or dementia.

B) Visual loss and erectile dysfunction

At the time of diagnosis and at regular

intervals thereafter:

all older people with diabetes should have a

standard visual acuity assessment and retinal

examination .

Although direct ophthalmoscopy is a useful

tool for screening in older patients,

they are no substitute for retinal photography and slit lamp

examination in the screening for diabetic retinopathy.

To maintain vision in older patients with

type 2 diabetes and established retinopathy,

optimal blood pressure control (≤140/80 mmHg)

optimal glycaemia (HbA1c 7.0– 7.5%) should be

aimed for.

Older adults with diabetes and erectile

dysfunction

require a comprehensive evaluation of underlying risk

factors.

A detailed cardiovascular evaluation

Oral phosphodiesterase type 5 inhibitors, unless

contraindicated, as a first-line therapy

Each older adult with type 2 diabetes and

cardiovascular disease:

should be asked about their sexual

health.

c) Peripheral neuropathy and pain

1. At the time of diagnosis and at regular

intervals thereafter older patients with

diabetes

should be questioned about symptoms of

neuropathy

examined for the presence of peripheral

neuropathy

2. Gabapentin can be used in older patients

and is superior to placebo in painful diabetic

neuropathy

have fewer side-effects than tricyclic

antidepressants (TCAs).

3-Duloxetine an alternative treatment

for diabetes-related neuropathic pain when

given at doses of 60mg or 120mg daily.

Elderly patients with diabetes are generally

treated following the same approach as in

younger patients:

dietary therapy first,

followed by oral hypoglycaemic agents

insulin.