Clinical management of elderly people with diabetes

1. Prof. Leocadio Rodríguez Mañas
Geriatrics Service
Getafe University Hospital
Universidad Europea de Madrid
España
Clinical management of elderly people
with diabetes
24 October 2015
PCDE Session

2. Prevalence of diabetes
Di@bet.es study
0
5
10
15
20
25
30
35
40
45
18-30 31-45 46-60 61-75 >75
Known DM Unknown DM
0
5
10
15
20
25
30
35
40
45
18-30 31-45 46-60 61-75 >75
Known DM Unknown DM
Male Female
Soriguer F. Diabetologia 2011

3. TOPICS
 Do they need a different approach?
 Different pathophysiology
 Different risks
 Different targets
 Different management
 Conclusions

4.  Older people
 Oxidative phosporilation <40%
 Decrease in ATP synthesis
 Acumulation of intramyocelular lipids
 Like Relatives of patients with Type 2
DM
 But without obesity
Science 2003; 300: 1140-2
Science 2005; 307: 384-7
Am J Med. 2006; 119 (Suppl 1): S10–S16.
Insulin resistance

5. Loss of muscle mass
Vandervoort
Muscle and Nerve 25,
31 yrs (M)
66 yrs (M)
73 yrs (F)
85 yrs (M)
Buford et al,
Exp. Gerontol, 2012
Plus changes in
adipose tissue?
Plus changes in
muscle bioenergetics?

6. El Assar M, Angulo J, Rodriguez-Mañas l. J Physiol 2015
MECHANISMS OF VASCULAR DAMAGE

7. DM and Mortality
Bertoni AG. Diabetes Care 2002;25:471-475
0
0,5
1
1,5
2
2,5
65-69 70-74 75-79 80-84 >85
Age
Mortalityrate
Females
Males

8. Cognitive dysfunction should be added to the list of the complications of diabetes,
along with retinopathy, neuropathy, nephropathy and cardiovascular disease.
The older patient with diabetes
 Older persons with diabetes are at
higher risk than those without
diabetes of:
 Cancer mortality and vascular
deaths
 Functional disability
 Geriatric syndromes:
depression
 Falls and fractures
 Geriatric syndromes: cognitive
impairment
Ageing and
Diabetes
Cognitive
dysfunction
Falls and
fractures
Functional
disability and
depression
Cukierman T, et al. Diabetologia. 2005;48(12):2460-9.
CV disease,
cancer and
all cause
morbidity/
mortality

9. DIABETES AND FUNCTIONAL IMPAIRMENT
Wong et al.,
Lancet Diabetes and Endocrinol., 2013
Diabetes? What about my flight?

10. No
diabetes
Non-insulin-treated
diabetes
Insulin-treated
diabetes
n 8.620 530 99
Incidence of falls (per
person-year)
70–74 years old 0.43 0.56* 1.26*
75–79 years old 0.52 0.74* 0.82*
80–84 years old 0.66 0.89* 1.31*
85 years old 0.98 1.32* 1.37*
All ages 0.62 0.85* 1.12*
Fall more than once a year
(%)
17.0 25.7* 35.4*
Fall more than twice a year
(%)
6.8 10.6* 15.2*
Follow-up (years) 7.2 ±
1.9
6.6 ± 2.2* 6.2 ± 2.4*
Diabetes and Risk of Falls
Schwartz A, JAGS 2002

11. DM2 and risk of hip fracture
RRl: 1,7 (IC: 1,3-2,2)
Janghorbani M, et al. Am J Epidemiol. 2007; 166: 495–505.

12. DM (n) No DM (n) Risk and 95% CI
Hassing et al 38 220 2.1 (0.99−4.4)
Leibson et al 1455 NA 1.7 (1.3−2.0)
Macknight et al 503 5071 1.2 (0.9, 1.7)
Ott et al 689 4532 1.9 (0.9−1.7)
Peila et al 900 1674 1.5 (1.0−2.2)
All participants 2723 10044 1.6 (1.4−1.8)
0.01 0.1 1 10 100
 Development of future dementia
 The odds of future dementia is increased 1.6-fold
Cukierman T, et al. Diabetologia. 2005;48(12):2460-9.
Development of dementia in patients
with type 2 diabetes
DM= diabetes mellitus

13.  Focused on preservation of function
 Tailored to the characteristics of the
patient
 Avoiding undesired effects of
treatment (hypos)
But also
 Timely
NEW OBJECTIVES
for new challenges,
MEAN
a different management

14. What is going to happen after death….
….SIMPLY, IT DOES NOT HAPPEN
When you have the appointment for surgery?
In one month, but I do not know if I will come,
because it does not disturb me currently

15. 15
10
0
20
5
25
65 70 75 80 85 90 95
Hombres Mujeres 2004
HTA
c-LDL
HbA1c - micro
HbA1c - macro
INE. Anuario Estadístico, 1997.
Tiempo necesario para obtener beneficios del
control de los FRCV en sujetos >65 años

16. 15
10
0
20
5
25
65 70 75 80 85 90 95
Male Female 2004
INE. Anuario Estadístico, 1997.
Life-expectancy in Spain for people
older than 65 yrs
Time for functional decline
Mobility disability
Frailty
BADL
Dementia posthypos

17. TOPICS
 Do they need a different approach?
 Different pathophysiology
 Different risks
 Different targets
 Different management
 Conclusions

18. OCTOBER, 2015

19. LONGEVITY
(AMOUNT OF LIFE)
QUALITY OF LIFE
(FUNCTION)
CHRONIC
DISEASE
HEALTH
SYSTEMS
+
SOCIAL
SYSTEMS
Prevention
Risk manag.
Empowerment
Integrated
Coordinated.
Continued
 Management of chronic disease oriented to avoid frailty and preserve function
 Management of frailty, as the phenotypic expression of disease in older adults
 Management of frailty, as the main predictive factor of adverse outcomes
 Promoting integrated, coordinated and continued care
OUR CHALLENGE
OUR APPROACH
TO MAINTAIN

20. COMPREHENSIVE BIOPSYCHOSOCIAL ASSESSMENT
Sinclair AJ. Diabetes Spectrum. 2006;19(4):229-33. Haas L. Diabetes Spectrum. 2006;19(4):240-4.
HOW TO ACHIEVE
AN OPTIMAL
MANAGEMENT OF
OLDER ADULTS
WITH DM
Avoid symptoms
of hyperglycemia
Prevent undesired
weight loss due to
inapropritae diets
Prevent vascular
complications
Avoid
hypoglycemia
Avoid Adverse
Drugs Reactions
Prevent
cardiovascular risk
Improve quality
of life
FUNCTION
INDIVIDUALIZED AIMS OF TREATMENT

21. Defining functional
categories
Defining functional categories
Initial clinician
assessment
Vascular complications
profile
Physical
function/frailty/cognition
Comorbidities/Drugs
Consideration of Findings
Total/active life expectancy
Risk of complications
Competing risks
Need for carer/social support
Hypoglycaemia and ADR* risk
Individualised management of the patient
Nutrition, physical activity/exercise, drugs, level of care, coordination of
care
Independent Frail Physical/ End of life
robust cognitive impairment
Focus on disease
Focus on function
ADR: adverse drug
reaction
Sinclair AJ, Dunning T, Rodriguez-Mañas L
Lancet, Diabetes Endocrinol, 2015

22. Clinical assessment of older people with Type 2 DM
Patient willings and
preferences
Frailty and shorten life
expectancy
Polipharmacy
Comorbidities and
risk factors
Cognitive
impairment
Social isolation/loneliness
Unvoluntary weight loss
Depression
Factors to take into account in the proper
management of older people with DM
Sinclair AJ. Diabetes Spectrum. 2006;19(4):229-33.

23. Robust Frail Functional
Limitation
Disability Dependency
Definition
Interventions to
improve quality
and outcomes -
and prevent or
delay further
functional
decline
What
How
Where
?
What
How
Where
?
What
How
Where
?
What
How
Where
?
What
How
Where
?
Potential reversibility of
functional decline
Frailty and function as a dynamic state
CARE FOCUSED ON
Preventing
frailty
Preventing
Disability
Treating
Frailty
Preventing
Disabilty
Treating
Functional
Decline
Preventing
Dependency
Treating
Disability
Managing
Dependency

25. DM ALONG THE TIME
1922
PRE-
TREATMEN
T
¡¡FIRST TREATMENT WITH INSULIN!!
POST-
TREATMEN
T
Focused on
• Type 1 DM
• Children/Young people
• To Save lives
• Starvation

26. 1969
Abdominable
Focused on
• Type 2 DM
• Middle-age people
• To Save lives
• CVD
DM ALONG THE TIME

27. 2015
Focused on
• Type 2 DM
• Older adults
• To avoid disability
• To avoid dependency
DM ALONG THE TIME

28. TO PROVIDE THE BEST FITTED
CARE TO OUR PATIENTS WE
SHOULD MOVE TOWARDS THIS NEW
AGE IN DIABETES
CONCLUSIONS
 NOWADAYS, OLDER ADULTS REPRESENT
50% OF PERSONS WITH DM
 THEY SHOW DIFFERENT CHARACTERISTICS
 THEY NEED DIFFERENT APPROACHES
 THEY NEED DIFFERENT MANAGEMENT
 FRAILTY IS BOTH AN OUTCOME AND A
CONDITIONING FACTOR
 FRAILTY MUST BE ASSESSED IN ANY OLDER
ADULT WITH DM AS A FUNDAMENTAL PART
OF THE DECISSION-MAKING PROCESS
leocadio.rodriguez@salud.madrid.org
FACING THE RISKS FOR
DISABILITY IN DIABETES