Diabetes Elderly Management dr Manash.ppt

Management of diabetes in the elderly

1. Management Of Diabetes In The
Elderly
Challenges & Solutions
Dr Manash P Baruah, MD, DM
Director & Consultant Endocrinologist,
Excel Centre, Guwahati, INDIA

2. THIS PRESENTATION WAS MADE IN THE 1
ST
BITS-WORLD CONGRESS OF DIABETES IN
BEIJING ON 16
TH
JUNE, 2012

3. DISCLAIMER
Research Grant: Novo Nordisk, USV(I)
Travel Grant: Novo Nordisk, USV(I), MSD
pharma, Novartis, Abbot, Aventis
Consultancy Fees: USV(I), MSD pharma,
Novartis, Abbot, Aventis

4. DIABETES IN THE ELDERLY
Do we have a problem here?
If so,
What’s the magnitude of the problem?

5. ELDERLY POPULATION: DEFINITION & STATISTICS
Definitionof“elderly”orolderperson=>65y.
Globalperspective2050:Absolutenumberabout2
billion(1/3rdoftotalpopulation)
India2002,theabsolutenumberabout75million.BY
2016,9%ofallIndianswillbe>65y
China2006,108million,8%oftotal;China2050,
322million,24%oftotal.
 UNWorldPopulationAgeing;2009
PopulationprojectionforIndiaandstates-1996-2016.CensusofIndia1991(Report).NewDelhi:Registrar
General,India;1996.
Inter-MinisterialCommitteeonAgeingReport.MinistryofCommunityDevelopment:Singapore:1999.
Park’sTextBookofPreventiveandSocialMedicine.In:M/sBanarsidasBhanotPublishers,India.2007

7. High Prevalence of T2DM Among Elderly0
5
10
15
20
40-49 50-59 60-74
Age (years)
Previously diagnosed diabetes
Newly diagnosed diabetes by FPG
Newly diagnosed diabetes by OGTT (IPH)
Harris MI, et al. Diab Care. 1998;21:518-524.
Resnick HE, et al. Diab Care. 2000;23:176-180.
Percentage of Population
NHANES III

8. PREVALENCE OF DIABETES MELLITUS IN SOUTH ASIAN ASSOCIATION
FOR REGIONAL COOPERATION (SAARC)COUNTRIES
2009

9. CRITICAL QUESTIONS
1.Why elderly are more prone to Diabetes?
2. What are the constraintsin the management of
diabetes in elderly?
3. What glycemic targetscan be recommended?
4. What treatmentoptions are available for achieving
recommended glycemic targets safely and effectively
in this elderly population with different co-
morbidities?
5. What systems need to be in place to achievethese
recommendations?

10. WHY ELDERLY ARE MORE PRONE TO DIABETES?
Pathophysiologyof Aging Leading to Diabetes
Clin Geriatr Med.2007;23(4):785-808

11. Peculiar Presentation of Glycemia
•Most patients have an FPG of ≤ 125 mg/dl while
PPG remains mostly > 200 mg/dl.
•Thus elderly are more exposed to the risk of
developing cardiovascular morbidities.
Lancet.1999;354(9179):617-21. J EndocrinolInvest.2005;28(11 Suppl):105-7.
<60years>85years
Prevalenc
e of IGT
8.8-11% 24.-34.7%
Data from the Rotterdam Study
Am J Epidemiol. 1997;145:24-32.

12. General Issues & constraints in the
Management of Diabetes in Elderly

13. Inadequate Treatment
•According to a study, among patients with previously treated
& diagnoseddiabetes, the likelihood of treatment declined
with older age.
•Although the prevalence ofdiabetesincreases with age and
the risks of many consequences ofdiabetesremain high, the
rate of drug treatment fordiabetesdeclineswith older age &
greater co-morbidity.
The reason?
•Concern about side effects
•Reduced treatment benefits due to competing risks of death.
J Clin Epidemiol. 1999;52(8):781-90.

14. Associated Co-morbidities
•Atherosclerotic Cerebro-vascular disease
•Cerebral Ageing
•Malignancies
•Compromised cardio-respiratory reserve
•Fluid & Electrolyte imbalance
•Cataract
•Neuropathy (specially autonomic)

15. Elderly Diabetics & Cognitive Function
CONCLUSIONS:
Elderly subjects with predominantly Type 2 diabetes mellitus
display significant excess of cognitive dysfunction,
associated with poorer ability in diabetes self-care and
greater dependency. Routine screening of cognition in older
subjects with diabetes is recommended
Sinclair AJ, Girling AJ, Bayer AJ.Diabetes Res Clin Pract.2000 Dec;50(3):203-12
Test T2 Diabetc Non Diabetic elderly P
MMSE score >24 71% 88% <0.0005
Clock testing 65% 76% <0.001
The AWARE(All WAlesResearch into Elderly)study:
Cognitive dysfunction in older subjects with diabetes mellitus:
impact on diabetes self-management and use of care services.

16. Elderly Diabetics & Cognitive Function
•Type 2 diabetes mellitus is associated with a 1.5-2.5-fold
increased risk of dementia in elderly.
•Data suggest that the brains of older people with type 2
diabetes mellitus might be vulnerable to the effects of
recurrent, severe hypoglycemia.
•Severe hypoglycemia can result in permanent neurological
sequelae including neuronal cell death, which may accelerate
the process of dementia.
•Atheroscerotic Cerebrovascular disease is also a possible
mechanism for the association between episodes of
hypoglycemia and increased risk of dementia.
Nat Rev Endocrinol.2011;7(2):108-14. JAMA.2009;301(15):1565-72.

17. Risk Factors Contributing to Hypoglycemia
in the Elderly
Baruah MP et al .Indian J Endocrinol Metab. 2011;

18. Hypoglycemia is associated with CV events such as MI,
angina and sudden cardiac death
Hypoglycemia Linked to Increased CVD Risk
Diabetes Care. 2010;33(6):1389-1394

19. Glycemic Targets for Geriatric Population
Clev Clin J Med. 2008;175:5-9 DiabetesCare.2012;35(6):1364-79.
Guidelines HbA1c Target
ADA 2012 < 7.0%
Functional, cognitively intact older adults with significant life
expectancies should receive diabetes care using goals developed
for younger adults
Department of
Veterans Affairs
2003
7.0% in adults with life expectancyof > 15 yrs along with good
functional status (no major co-morbidity)
8.0% if frail or if life expectancy is 5-15 yrs (in the presence of
moderate co-morbidities)
9% if life expectancy is < 5 yrs (major co-morbidities)
American
Geriatric Society
2003
< 7.5% in adults who have good functional status
8% if frailor if life expectancy is < 5 yrs
ADA-EASD
Consensus 2012
7.5 –8 % + inolder patients, co-morbidities, hypoglycemia prone
etc.

20. Raising HbA1c target is not enough
93% of hypoglycemic episodes(byCGMS) were unrecognized by
finger prick monitoring or by symptoms
69% of patients experienced Nocturnal Hypoglycemia (all by
CGMS: No patient could recognize on own)
Parameter HbA1c
8%-9%
HbA1c
>9%
P
Frequency of hypo episodes 4.3 3.7 NS
Duration(Hrs) of hypo episodes 3.5 2.4 NS
Severe (50<%)mg/dL) 1.2 1.1 NS
No. of unrecognized episodes 2.5 4.6 NS
mean [SD] Cr Cl mL/min 83[37] 89[37]NS
[MunshiMN, Segal AR, Suhl E, et al .Arch Intern Med. 2011;171(4):362-364.]

21. Strategies to Safely Manage Glycemia
in Elderly

22. Safety Issues & Monitoring Therapy for
Better Glycemic Control
•Managing diabetes effectively involves patient & family
education regarding:
•Signs & symptoms of hypoglycemia
•Carrying replacement glucose in pocket
•Practicing self-management.
•Important to conduct annual self-management training.
•Patient heterogeneity must be taken into consideration by
clinicians for older adults with diabetes while setting &
prioritizing treatment goals.
Baruah et al .Indian J Endocrinol Metab. 2011;15(2):75-90

23. Components of Initial Clinical Evaluation
•Complete history & physical examination of the patient.
•Geriatric assessment
•Laboratory examination
•FPG, PPG, HbA1c
•Lipid profile
•Kidney function tests
•Routine urine analysis
•Liver function tests
•ECG
•Ophthalmological examination including fundoscopy
•Dietary assessment
Baruah et al. Indian J Endocrinol Metab. 2011;15(2):75-90

24. Continuum of Care in Elderly
•Treatment approach needed to meet target blood glucose
levels (avoiding complications like hypoglycemia & weight
gain):
•Diet,
•Oral agents,
•Incretin-based therapy or
•Insulin.
•Evaluation of blood glucose levels as frequently as needed.
•Annual assessment of diabetes complications.
•Annual assessment for common geriatric co-morbidities.
Baruah et al. Indian J Endocrinol Metab. 2011;15(2):75-90

25. Treatment Considerations in Elderly
•Individualized
•Weigh risks of hyperglycemia with hypoglycemia
•No data that tight control prevents stroke or cardiovascular
events or improves mortality in this age group
•Risk of “polypharmacy”, increased risk of side effects and
drug-drug interactions
•Treatment must be practical: are there functional limitations
that will make plan of care difficult
Safety is the prime issue in the approach to achieving
the glycemic goals in elderly diabetic patients
Baruah et al. Indian J Endocrinol Metab. 2011;15(2):75-90

26. HYPERGLYCEMIA THERAPY : THE BASKET
Insulin sensitizers: Biguanide, Thiazolidinediones
Insulin secretagogues: Sulfonylureas,
Meglitinides
Drugs retarding the absorption of glucose from
gut: AGIs
Incretin enhancers: Oral inhibitors of DPP-IV,
GLP-1 receptor agonists
Novel oral agents: Dopamine 2 modulator, SGLT2
inhibitors
Insulins

27. OADs in Elderly: Metformin
•Remarkable advantages:
•Weight neutrality
•No tendency of causing weight loss
•Inexpensive
•Immensely useful in obese diabetics with HbA1c reduction
ability 1-2%.
•Significantly reduces all-cause mortality and diabetes-related
endpoints.
•However inappropriate to use in older patients
•Who are frail, anorexic or underweight
•With Congestive Cardiac Failure
•With compromised renal or hepatic function
Drugs Aging. 2005;22:209-218 Am J Geriatr Pharmacother. 2009;7:324-334

28. ADA-EASD 2012 Recommendation for
Metformin in Renal Impairment
DiabetesCare.2012;35(6):1364-79.

29. Metformin Therapy in Elderly Diabetics
South Asian Consensus Recommendations
•Conservative initiation with a low dose & a very careful
upgradation of the dose to avoid GI intolerance.
•Advisable to use SR formulation whenever possible.
•Extreme care to be taken when using it in persons who are
frail & > 80 yrs of age.
•Patients using metformin should be checked for vitamin B12
status every 4-5 yrs. Supplementation should be provided
wherever applicable
•Foremost consideration should be given for periodically
monitoring renal function.
Indian J Endocrinol Metab. 2011;15(2):75-90

30. OHAs in Elderly: Thiazolidinediones
•TZDs have been recommended as monotherapy &
combination for the treatment of T2DM.
•However, in elderly subjects they can cause adverse effects
such as
•Fluid retention
•Propensity to develop or worsen heart failure
•Hepatic toxicity.
•As compared to rosiglitazone, pioglitazone is not associated
with increased risk of cardiac morbidity & mortality.
•Recently described risks (osteoporosis, bladder cancer) are
more relevant in the elderly.
•It is recommended that TZDs may not be preferred over
metformin in the treatment of diabetes in elderly.
•In compelling situations use minimal dose
Am J Geriatr Pharmacother. 2009;7:324-334, Indian J Endocrinol Metab. 2011;15(2):75-90

31. OADs in Elderly: Sulfonylureas
•Cornerstone of hyperglycemia management in the elderly.
•More than 70% prescriptions given to individuals over 60 yrs
of age.
•Generally well tolerated except for hypoglycemia.
•Among all SUs, glibenclamide is associated with serious
hypoglycemia.
•Gliclazide and Glipizide are the preferred options especially in
elderly diabetics.
Drugs Aging. 2004;21:511-530 Indian J Endocrinol Metab. 2011;15(2):75-90

32. Use of Sulfonylureas in Elderly Diabetics
South Asian Consensus Recommendations
•Avoidance of glibenclamide in all elderly diabetic subjects .
•Preferable to use agents with single daily dosing schedule –
Gliclazide XR, Gipizide XL in situation where dosing error may
occur.
•Conservative approach during initiation, uptitration &
maintenance.
•SUs may not be the right choice in patients with
•Compromised renal function
•Patients with irregular meal patterns, patients tending to skip meals etc.
Indian J Endocrinol Metab. 2011;15(2):75-90

33. Meglitinides in Elderly Diabetics
•Rapid acting non-SU insulin secretagogues with relatively
short half-life.
•Potential to cause hypoglycemia, but lesser risk as compared
to SUs.
South Asian Consensus Recommendations
•Use of meglitinides is advocated in patients with moderate
renal impairment & normal hepatic function.
•Unlike SUs, conservative dosing is not mandatory.
•Can be used as an adjunct to long-acting basal insulin.
•
•Higher motivation required regarding dosing errors
Drugs Aging. 2004;21:511-530 Indian J Endocrinol Metab. 2011;15(2):75-90

34. Incretin Enhancers in Elderly Diabetics
South Asian Consensus Recommendations
GLP-1 analogues
•GLP-1 analogues may be a suitable option in relatively
younger patients (< 75 yrs) who are overweight or obese
(more evidence required)
•DPP-4 Inhibitors
•DPP-4 inhibitors are a natural choice for hyperglycemia
management in elderly in normal-moderate renal impairment.
•Vildagliptin is the preferred choice in the sub-group of patients
> 75 yrs of age.
•These drugs are suitable irrespective of body structure (frail &
robust alike).
.
Indian J Endocrinol Metab. 2011;15(2):75-90

35. Incretin Enhancers: Oral DPP-IV Inhibitors
Natural choice of oral drugs for elderly
NICE (UK) recommends their use (instead of SUs) as
an add-on to the ongoing metformin therapy if :
Glycemic control is inadequate (HbA1C > 6.5%)
At significant risk of hypoglycemia or its
consequences
√ older people,
√ those living alone,
√ those working at heights or with heavy
machinery.
.
Available from: http://www.nice.org.uk. [cited in May 2009].

36. Incretin Enhancers: Oral DPP-IV
Inhibitors
Agent SitagliptineVildagliptineSaxagliptineLinagliptine
RDD 100mg OD 50mg BID 5mg OD 5mg OD
? Differential
dosing for elderly
No No No No
Mod RF, CrCl<50
mL/min
50mg OD ? 2.5mgOD 5mg OD
Advanced RF(CrCl
<30ml/min),
25mgOD ? 2.5mgOD 5mg OD
Dose ↓ mild liver
dysfunction
None ? None 5mg OD
Trials specifically in
Population>75y
None Yes None None

37. Novel Agents in Elderly: SGLT2 Inhibitors
•Target hyperglycemia independent of insulin –negligible risk
of hypoglycemia.
•Multiple pleotropic effects.
•However, associated with potential negative effects such as
•Higher rate of urinary and genital infection
•Hyperparathyroidism
•Increased hematocrit
•No focused study of SGLT2 Inhibitors in elderly diabetics as of
now.
Expert Opin Investig Drugs. 2010.19:1581-1589

38. Novel Agents in Elderly: Bromocriptine
•Recently approved for use in T2DM.
•May be useful in elderly patients with diabetes and
parkinsonism symptoms, obese depressed patients with
limited mobility and features of insulin resistance.
South Asian Consensus Recommendations
•Use of novel drugs particularly in elderly patients with T2DM
seems promising but….
•More evidence to have conclusive evidence in this regard
Int J Clin Cases Invest. 2010;1:1-2 Indian J Endocrinol Metab. 2011;15(2):75-90

39. Insulin Therapy in Elderly
•Insulin remains the best and most cost-effective option for
diabetic patients, both young & old.
•Insulin has no dose-limit & no contraindications for use unlike
OHAs.
•However, there is general reluctance by physicians & patients
to accept insulin since –
•Fear of hypoglycemia
•Loss of independence (perceived)
•Weight gain
•Cost
•Patient identified barriers: pain of injection, anxiety of potential side
effects, complexity of regimens etc.
•Age-related changes can result in functional disability to administer
insulin.
Diabetes Educ. 2004;30:274-80 J R Soc Med. 2002;95:453-455

40. Comparison Of Acceptability Of Injection Device Vs.
Conventional Syringes By Elderly Diabetic Patients.
Outcome of
questionnaire
Favors pen
device (%)
Favors
syringe
device (%)
Favors none
(%)
Easy and quick
operability
88 12 00
Pain experienced
during injection
62 02 43
Easy pre-selection
of insulin dose
86 14 00
Overall
acceptability
90 02 08
Coscelli et al. Diab Res Clin prac 1995

41. Indications for Insulin Therapy in Older
Adults with T2DM
** Relative indications
Indian J Endocrinol Metab. 2011;

42. USING INSULIN IN ELDERLY DIABETIC: ROLE OF BASAL
INSULIN: INITIATION WITH BEDTIME BASAL, SIMPLE WAY TO
START
The challenge : nocturnal hypoglycemia,
NPH> >Analogue (28.8% vs. 12.6%, P = 0.011)
WHY
PeakactivityofNPH,whichusuallyoccursat6-8hours
followingtheinjection,mightcoincidewiththemostinsulin
sensitiveperiodoftheday,i.e.midnight.Lowcortisolis
themostimportantcontributingfactor.
Remedy: Inject NPH as late as possible, preferably before
midnight.(Disadvantageous)
Or use Analogue : any time of the day(Lantus), Any time in
the evening(Detemir)
HOE study group. Diabcare 2000,(23) Baruah et al IndJ EndocrinoolMetab2011

43. PROTOCOL OF INITIATION & INTENSIFICATION OF BASAL
INSULIN RX
Ste p1Adjust insulin
doses once or
twice every week
according FBG
Mean FBG mg/dL Adjustment in insulin
dose (otherwise healthy
elderly,age<75years))
Adjustment in insulin
dose (Frail elderly,
presence of significant
co-morbidities,
age>75years))
Initiation 0.1-0.2 u/kg body weight0.1u/kg body weight
>180 Increase by 8 unitsIncrease by 6 units
150-180 Increase by 6 unitsIncrease by 4 units
130-150 Increase by 4 unitsIncrease by 2 units
110-130 Increase by 2 unitsNo change
90-110 No change Decrease by 2 units
<90 Decrease by 2 unitsDecrease by 4 units
<70 Decrease by 4 unitsDecrease by 6 units
Step 2Match overall glucose control with HbA1c
Step 3If FBG is on target ,but HbA1c is not, look for evening blood glucose, add morning basal to
keep evening blood glucose at 110-130mg/dl range
Step 4If FBG and evening blood glucose are on target ,but HbA1c is not, look for post prandial blood
glucose, add prandial rapid acting insulin to keep maximum post meal peak between 140-
180mg/dl
South Asian Geriatric Guidelines: Indian J Endocrinol Metab.2011 Apr

44. Significance to Other Paradigms:
Patient Education
•Individuals should be informed about benefits of exercise &
available resources for becoming more active.
•The older adult with diabetes & any caregiver should receive
education about risk factors for foot ulcers & amputation.
•Physical ability to provide proper foot care should be
evaluated.
Int J Geriatr Gerontol. 2009;5:1

45. Significance to Other Paradigms:
Diet
•Keeping in view the special considerations in the elderly,
quality, quantity & frequency of the diet intervention have to
be modified.
•However the total calories & its distribution should more or
less correspond to the standard dietary therapy.
•The 8 A’s of the geriatric diet prescription.
•Accurate
•Appropriate
•Available/accessible
•Acceptable
•Attractive
•Achievable
•Affordable
•Absorbable/digestible
Am J Geriatr Pharmacother. 2009;7:324-334

46. Significance to Other Paradigms:
Physical Activity
•The potential benefits of exercise in elderly are
•Improved glucose tolerance
•Improved maximum oxygen consumption
•Increased muscle strength
•Decreased Blood pressure, body fat
•Improved lipid profile & sense of well-being.
•However risks associated with exercise in elderly include
sudden cardiac death, hypoglycemia, foot & joint injuries etc.
•Hence, before initiating an exercise program in elderly, the
patient should undergo detailed medical evaluation with
appropriate diagnostic studies.
Indian J Endocrinol Metab. 2011;15(2):75-90

47. In summary
•World population of elderly is increasing, that with
T2 Dm is increasing disproportionately more.
•Diabetes in elderly can now be managed better due
to the availability of multiple options in the treatment
armamentarium.
•It is essential to choose the treatment goals
appropriately & the available pharmacological
agents judiciously.

48. IN SUMMARY (CONTINUED)
•The foremost aim in these group of patients is
steady achievement of goals while doing “no harm”.
•Physicians need to underscore the importance of
“shared healthcare approach” involving counselors,
nutritionists, physiotherapists, community workers,
local doctors.
•There is s strong case for developing specialist
Geriatric Diabetology as a separate speciality(like
pediatrics).

49. Adding yearsto life,
Adding lifeto years

50. Indian J EndocrinolMetab.2011 Apr;15(2):75-90.
Management of hyperglycemia in geriatric patients with diabetes mellitus: South
Asian consensus guidelines.
BaruahMP, KalraS, UnnikrishnanAG, RazaSA, SomasundaramN, John M, Katulanda
P, ShresthaD, BantwalG, SahayR, LattTS, PathanF.
Source
Department of Endocrinology, Excel Center, Guwahati, India.
Abstract
Asia is home to four of the world's five largest diabetic populations, two of them being
South Asian nations, namely, India and Pakistan. This problem is compounded by a
substantial rise in the elderly population in Asian countries. On the other hand, the
heterogeneous health condition and multiple co-morbidities make the care of chronic
disease in the elderly a challenging task. The aim of the South Asian Consensus
Guidelines is to provide evidence-based recommendations to assist healthcare
providers in the rational management of type 2 diabetes mellitus in the elderly
population. Current Guidelines used systematic reviews of available evidence to form
its key recommendations. No evidence grading was done for the purpose of this
manuscript. The clinical questions of the guidelines, the methodology of literature
search, and medical writing strategy were finalized by consultations in person and
through mail. The South Asian Consensus guideline emphasizes tailoring of glycemic
goals for patients based on age, co-morbid conditions especially that of
cardiovascular system, risk of hypoglycemia, and life expectancy. It also
recommends cautious use of available pharmacotherapy in geriatric patients with
diabetes. The primary principle of diabetes therapy should be to achieve euglycemia,
without causing hypoglycemia. Appropriate use of modern insulinsand oral drugs,
including incretin mimeticswill help physicians achieve this aim.
PMID: 21731863 [PubMed-in process]
ManashP Baruah Consultant Endocrinologist, Excel Center, Guwahati, , India
Sanjay Kalra Consultant Endocrinologist, BhartiHospital and BRIDE, Karnal, Haryana,India
A G Unnikrishnan Professor of Endocrinology, Amrita Institute of Medical Sciences, Kochi, India
SyedAbbasRaza
ConsultantEndocrinologist, ShaukatKhanumMemorial Cancer Hospital and Research
Centre, Lahore, Pakistan
Noel Somasundaram Consultant Endocrinologist, National Hospital of Sri Lanka, Colombo, Sri Lanka.
Mathew John
ConsultantEndocrinologist,Providence Endocrine & Diabetes Specialty Centre,
Trivandrum, India
Prasad Katulanda Member, Faculty of Medicine, University of Colombo, Colombo, Sri Lanka
Dina Shrestha ConsultantEndocrinologist, NorvicInternational Hospital, Kathmandu, Nepal
GanpathyBantwal Professor of Endocrinology, St Johns medical College, Bangalore, India
RakeshSahay Professor of Endocrinology, Osmaniamedical College, Hyderabad, India
Tint SweLatt Rector, University of Medicine 2, Yangon, Myanmar
FaruquePathan Professor of Endocrinology, BIRDEM Hospital, Dhaka, Bangladesh

51. ACKNOWLEDGEMENT
Mr Sandip Mitra
Dr B S Mohan

52. THANK YOU