Elderly with Diabetes in Primary Care
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Elderly with Diabetes in Primary Care.
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Elderly with Diabetes in Primary Care
- 1. Elderly with Diabetes in Primary Care Serap Çifçili Marmara University Medical Faculty Department of Family Medicine PCDE - İstanbul, 2015
- 2. Outline • Screening • Basic Principles of care • CV risk assessment and management • Adjustment of targets • Treatment; exercise, medical nutrition therap, pharmacological treatment • Hypoglycemia risk • Persistent hyperglycemia • Screening of complications • Other considerations PCDE - İstanbul, 2015
- 3. Screening • Same principles with adults • Isolated post-challenge hyperglycemia is common • Screen high risk individuals with OGTT or if not possible with HbA1C • HbA1C>6,5% may indicate presence of diabetes. PCDE - İstanbul, 2015
- 4. Basic Principles • Regularly assess functionality and self- management skills • Watch benefit-harm balance • Adjust targets • Individualize treatment • <85 Perform a CV risk assessment • Assess end-organ damage PCDE - İstanbul, 2015
- 5. Functionality and self management skills • At the time of diagnosis and annually – Global/Physical – Affective – Cognitive • Validated tools should be used • Multi-disciplinary team PCDE - İstanbul, 2015
- 6. Benefit-Harm Balance • Hypoglycemia vs hyperglycemia – Neuroglycopenic manifestations (dizziness, weakness, delirium etc) could be mixed with other manisfestations – Even mild hypoglycemia attacks may lead to falls. • Prevention of complications vs. polypharmacy PCDE - İstanbul, 2015
- 7. CV risk assessment and management • A cardiovascular risk assessment should be done. • Smoking cessation • ASA – for primary prevention insufficient evidence – for secondary prevention (known macro vascular disease) 75-325 mg dose PCDE - İstanbul, 2015
- 8. CV risk assessment and management • Blood Pressure – >140/80 mmHg (3 months three separate measurements, life style modifications) – Non-frail >80, 140-145 mmHg systolic/ <90 mmHg diastolic – Frail <150/90 mmHg – Renal disease ACE/ARB PCDE - İstanbul, 2015
- 9. CV risk assessment and management • Hyperlipidemia –No history of cardiovascular disease but 10 years CV risk >%15 –Proven CV disease –Statin unless contraindicated PCDE - İstanbul, 2015
- 10. Adjust Targets Physical condition HbA1C levels Fit elder 7.0-7.5% Frail elder 7.5-8.0 % Vey old 8.0-8.5 % PCDE - İstanbul, 2015
- 11. Individualize treatment: Exercise • Exercise should be recommended. (30 min/ 5 days moderate intensity aerobic) • Weight training should be included in addition to aerobic exercise. • Patients who have a risk of falling should be referred to a specialist • For asymptomatic adults, routine cardiac testing is not indicated before starting an exercise program unless the patients has high risk for coronary disease. PCDE - İstanbul, 2015
- 12. Individualize treatment: Medical Nutrition Therapy • Consider changes of ageing – altered taste, – dentition problems, – difficulty with shopping – memory decline, etc….) • Avoid complex dietary regimens • Obese older adults may benefit from caloric restriction. • Watch unintentional weight loss !!!!. PCDE - İstanbul, 2015
- 13. Drug Therapy • Metformin – eGFR≥60 mL/min full dose – eGFR=30-60 mL/min half dose – Start with 500 mg titrate slowly. – Stop if iv contrast is needed. – Follow up eGFR every 3-6 months. – Contraindications: renal dysfunction, hypersensitivity, metabolic acidosis anorexia, also check precautions PCDE - İstanbul, 2015
- 14. Drug Therapy • Insulin Secretagogue – Short acting SU (glipizide, ….) – Avoid glibenclamide (risk of hypoglycemia) • Dipeptidyl peptidase-4 (DPP-4) inhibitors – Add on to metformin or SU – Monotherapy for the patients whose HbA1C levels are close to target – Should be adjusted for patients with renal insufficiency • Glucagon Like Peptide-1 analogues – 3rd line therapy (very obese older people) PCDE - İstanbul, 2015
- 15. Insulin • Monotherapy or combination • Might be first line therapy esp. patients with A1C>9% • Assess ability to prepare and make insulin shots, monitoring blood glucose and recognizing hypoglycemia symptoms. • Older patients Premixed/Prefilled insulin pens • Long-acting insulin analogue (better hypoglycemia risk) • Titrate gradually (10 units or 0.2 units per kg) • Adjust the dose once weekly. • Lower dose in patients whose GFR<50 mL/min PCDE - İstanbul, 2015
- 16. Type 1 Diabetes Mellitus • Complex insulin regimens may become difficult to follow. • Long-standing diabetes in older adults is associated with severe hypoglycemia even when HbA1C level is 8%. • For the patients with vision impairments magnifiers or talking glucose meters can be used. • Frequent adjustments in insulin dosing, esp. During acute illness PCDE - İstanbul, 2015
- 17. Type 1 Diabetes Mellitus • Inconsistent food intake might lead to glycemic fluctuations. • In the presence of low and unpredictable food intake rapid acting insulin can be given right after meal. • The need for diabetic education should be periodically assessed. • Basal insulin should not be discontinued. • Fixed meal dosing and eating plan that provides consistent carbohydrates. PCDE - İstanbul, 2015
- 18. Type 1 Diabetes Mellitus • If the patient is on NPH insulin snacks may be needed. • Night time glucose level should be checked. • If the patient is capable, continuous subcutaneous insulin infusion help better glycemic control. • For the patients in facilities the staff should have diabetes education. PCDE - İstanbul, 2015
- 19. Hypoglycemia risk • After exercise • Skipping meals • Alcohol use • Altered renal fxn • GIS disorder • ACE inh, β-blockers, salicylates,…. • After being in hospital PCDE - İstanbul, 2015
- 20. Persistent hyperglycemia • Check dosing, diet, etc. • Pill-dosing dispensers might be helpful • Watch out for similar looking drugs!!!!! • Options are similar with adults • If the patient is on metformin add SU • Or add basal insulin • Other options are; repglinide, DPP-4 inh,GLP-1 receptor agonist • Consider patient characteristics PCDE - İstanbul, 2015
- 21. Screening for complications • Retinopathy, cataract and glaucoma – At least annually • Nephropathy • Foot exam – Every visit, – Assess self inspection skills PCDE - İstanbul, 2015
- 22. Other Considerations • Home Care Patients; screen on admission, comprehensive assessment for all diabetic. • Screen cognitive impairment and mood disorders (>70) with validated tools • Erectile dysfunction; – CV assessment – Oral phosphodiesterase inhibitors unless contrindicated. PCDE - İstanbul, 2015
- 23. Other Considerations • Symptoms and signs of neuropathy – 128 Hz tuning fork vibration, pin-prick test, monofilament test – Gabapentin, Duloxetine can be considered. • Falls and immobility; – falls risk assessment annually; medications, environmental items, gait and balance – Patients with history of falls; falls intervention program – Avoid tight glycemic control PCDE - İstanbul, 2015
- 24. Other Considerations • Peripheral arterial disease – Evaluate ABI • Depression is associated with poor glycemic control • Increased risk of urinary incontinence PCDE - İstanbul, 2015
- 25. Summary-1 • Evaluation of functional status is the first step • Hypoglycemia is of crucial importance • Adjust glycemic targets to HIGHER values • Avoid complex drug and diet regimens • Treatment options are similar with the adults • Follow-up complications very closely • Consider common geriatric syndromes and other geriatric issues PCDE - İstanbul, 2015
- 26. References • Sinclair AJ. Et.al. European Diabetes Working Party for Older People 2011 Clinical Guidelines for type 2 Diabetes Mellitus. Executive Summary. Diabetes and Metabolism 2011;37:S27-S38. • Buscher et.al. Primary Care Management of non-institutionalized elderly diabetic patients: The SAGES cohort – Baseline data. 2015; 9(4):267-274. • Chiniwala N, Jabbour S. Management of diabetes mellitus in the elderly. Curr Opin Endocrinol Diabetes Obes 2011;18:148-152. • Soe K. et.al. Management of type 2 diabetes mellitus in the elderly. Maturitas 2011;70:151-159. • Dhaliwal R, Weinstock RS. Management of Type 1 Diabetes in Older Adults. Diabetes Spectrum 2014;27(1): 9-20. PCDE - İstanbul, 2015
Notas do Editor
- Clinical presentation may be asymptomatic or non-specific. Basically same screening principles with adults apply. However, using only fasting blood glucose may not be enough. Isolated post challenge hyperglycemia is common in the elderly. Therefore, we should screen high risk individuals with OGTT or if not possible with HBA1C.
- Self-management of diabetes mellitus requires certain skills. At the time of diagnosis and follow-up, we have to evaluate the patient’s functional status. This evaluation should include three areas global/physical, affective and cognitive with validated instruments and with a skilled team.
- Vulnerability to hypoglycemia increases with ageing. Older adults may have more neuroglycopenic manifestations like dizziness, weakness, delirium etc.. and these symptoms might be confused with other pathologies. And even a mild hypoglycemia attack might cause adverse events like falls. Thus, we should consider hypoglycemia risk as an important factor while choosing a medication. Another topic is the prevention of complications. Sometimes these prevention efforts need prescription of new medications. However we must carefully think before adding a new agent to the treatment regimen.
- Absolute risk for cardiovascular diseases is higher for older adults. Following areas should be covered: Treatment of hypertension. Treatment of dyslipidemia, ASA therapy and exercise. CV risk assessment should be done to all elderly aged under the age of 85. Any modifiable CV risks should be discussed and managed. Among them; advice on smoking cessation should be offered. There is not sufficient evidence for routine use of ASA. However, for secondary prevention 75-325 mg ASA should be offered.
- Treatment of hypertension is another issue. It is beneficial including the patients over 80. The threshold for treatment of high blood pressure should be 140/80 mmHg for more than 3 months and measured at least on three separate occasions. And in this three months period, we should offer life-style modifications. For non-frail subjects older than 80 a blood pressure target around 140-145/<90 mmHg is recommended. For frail elderly a blood pressure goal of >150/90 mmHg is recommended. In patients with renal disease an ACE inhibitor or ARB is first choice.
- Absolute benefit of lipid lowering is greater than younger patients. The goals of lipid lowering should be adjusted according to the patients condition. In patients with no history of cardiovascular disease, a statin should be offered with an abnormal lipid profile and if their 10 year CV disease risk is >15%. Also a statin is recommended to the patients who have proven CV disease. Patients with hypertriglyceridemia after statin treatment might be considered for fibrate therapy.
- Adjustment of blood glucose targets according to global status. To avoid risk of hypoglycemia HbA1C targets should be adjusted. For the fit elderly a HbA1C level between 7.0-7.5% is reasonable, for frail elderly a level of 7.5-8.0 and for the very old 8.0-8.5 % are reasonable.
- Exercise is not only beneficial as an integral part of diabetes treatment but to maintain physical function, to prevent falls, sarcopenia and many other problems. In research of healthy ageing, exercise repeatedly proven to be beneficial. Along with aerobic exercise 30 min/ at least 5 days, weights training exercise should also be included.
- There are unique challenges of ageing complicating the medical nutrition therapy like altered taste, dentition problems, difficulty in shopping etc. These all should be taken into account while offering MNT. Basically while offering MNT avoid complex regimens. We know that obese alder adults may benefit from caloric restriction however we should carefully watch unintentional weight loss, since it increases risk of morbidity and mortality.
- Metformin should normally be the first-line treatment unless it is contraindicated. If the estimated GFR is over 60 mL/min we can start with full dose If it is between 30-60 mL/min we can start with half dose. Since metformin causes weight loss and gastrointestinal side effects, older patients may not use easily. So we can start with 500 mg and titrate slowly. If iv contrast is needed or the patients is ill for some reason then we should stop metformin.
- For patients who can not use metformin, we can start with a short acting SU like glipizide. We should avoid long acting SUs since their hypoglycemia risk. Other oral drug choices are DPP-4 inhibitors and GLP-1 mimteic DPP-1 inhibitors ore once-daily, no risk of hypoglycemia and weight neutral, however they are considerably weak. Therefore they should be used as monotherapy only if the patients blood glucose levels are close to target.
- Insulin might be underutilized in older patients because patients might not accept to use. If oral agents fail to lower glucose insulin might be given either as monotherapy or in combination. Also in patients whose HbA1C level is over 9% insulin might be used as first line therapy as well. I is important to assess the patient’s ability to prepare and make insulin shots before initiating insulin therapy. Or if a care-giver will make insulin shots, an agreement has to be made with this care-giver. For older patients premixed, prefilled insulin pens might work better. Also, long acting analogue insulin has a better hypoglycemia risk and might be preferred. Main principle is to start in small doses and to titrate very slowly in order to avoid hypoglycemia. A dose of 10 units or 0.2 units per kg is a good starting point. Dose can be adjusted weekly.
- Drug-induced hypoglycemia mostly occur after exercise or missed meals, eating poorly or abusing alcohol, if the patient has impaired renal function or gastrointestinal disease, drug therapy with salicylates, sulfonamides, fibric acid derivatesand warfarin. Also after being in hospital.
- If glycemic targets are not met by single agent we should first evaluate if there is any contributing factors like; difficulty adhering to medication,side effects,poor understanding of the nutrition plan etc.
- The prevalence of retinopathy increases progressively with duration of diabetes years. Regular eye examinations are extremely important. Poor vision leads to increases risk of falls and other accidents, impaired ability to manage diabetes (measure blood glucose or inulin doses etc) Cataract and glaucoma should be screened too, because both diseases are more common in the elderly diabetic patients than non-diabetic counterparts. Annual urinary albumin excretion is recommended however, if the patient is already taking ACE or ARB annual screening may not be helpful, because other reasons might cause increased urinary albumin excretion. Foot Problems: Risk of foot problems are also much higher in older patients The risk neuropathy is more than 50% in older diabetics. Also 30 percent of older diabetics cannot see or reach their feet. Therefore a foot exam should be done in every visit and this exam should include both exam of the foot and the patient’s self-inspection skills.