Transcript Diabetes in Elderly Adults - Isfahan University of Medical

Diabetes in Elderly Adults
Diabetes in Elderly Adults
• By the age of 75, approximately 20% of
the population are afflicted with this
illness..
• obese older patients have resistance to
insulin-mediated glucose disposal .
• delayed gastric emptying or gastroparesis
is frequently reported for older adults with
diabetes.
• Lean older patients with type 2 diabetes
had a marked impairment in glucosereduced insulin secretion . It has recently
been suggested that thin elderly diabetics
have a syndrome intermediate between
type 1 and 2 diabetes, which might
properly be thought of as type 1 1/2
diabetes.
• 50% older persons with diabetes are
unaware they have the illness, suggesting
that symptoms of hyperglycemia are
rarely present in this patient population.
• This may be because the renal threshold
for glucose increases with age, so that no
sugar is spilled into the urine until the
glucose level is markedly elevated. In
addition, because thirst is impaired with
normal aging, polydipsia is unlikely in
elderly patients with diabetes, even if they
are hyperosmolar as a result of marked
hyperglycemia.
• Often, diabetes presents for the first time
in an elderly person who is hospitalized
with a complication that may be related to
diabetes, such as a myocardial infarction
or a stroke. In frail elderly nursing home
patients, nonketotic hyperosmolar coma
may be the first sign of diabetes.
• The goals of DM care in older adults, as in
younger persons,
• include control of hyperglycemia and its
symptoms; prevention, evaluation, and
treatment of macrovascular and
microvascular complications of DM; DM
self-management through education; and
maintenance or improvement of general
health status.
• Chronically ill, institutionalized patients with a short life
expectancy do not require aggressive glucose control, but do
require adequate control to facilitate healing and prevent:
o Dehydration
o Symptoms of hyperglycemia or hypoglycemia
o Weight loss
Polypharmacy:
• Older adults with DM are at risk for drug
side effects and drug-drug and drugdisease interactions. Polypharmacy is a
major problem for older adults with DM,
who may require several medications to
manage glycemia, hyperlipidemia,
hypertension, and other associated
conditions.
Older adults tend to have less muscle than
younger people and generally have a higher
percentage of body fat. The elderly are
generally less hydrated than younger
individuals and thus tend to have less total
body water .Blood flow to organs such as the
kidneys and liver is diminished with age, which
can lead to decreased metabolism and
elimination of many drugs.
Polypharmacy:
• Clinicians should perform a careful review
of each medication currently being used
by the patient during the initial visit and at
each subsequent visit and document
whether the patient is taking each
medication properly.
Urinary Incontinence:
• The older adult who has DM should be
evaluated for symptoms of urinary incontinence
during annual screening.
women with DM are at higher risk than the
general population for urinary incontinence.
• The risk factors for urinary incontinence
that are more common in older adults with
DM include polyuria, overflow secondary
to neurogenic bladder and autonomic
insufficiency, urinary tract infection,
candida vaginitis, and fecal impaction due
to autonomic insufficiency. Urinary
incontinence is commonly unreported by
patients and undetected by providers.
Glycemic Control:
• For older persons, target hemoglobin A1c (A1C)
should be individualized. A reasonable goal for
A1C in relatively healthy adults with good
functional status is 7% or lower. For frail older
adults, persons with life expectancy of less than
5 years, and others in whom the risks of
intensive glycemic control appear to outweigh
the benefits, a less stringent target such as 8%
is appropriate.
• Chronically ill, institutionalized patients with a short life
expectancy do not require aggressive glucose control,
but do require adequate control to facilitate healing
and prevent:
o Dehydration
o Symptoms of hyperglycemia or hypoglycemia
o Weight loss
Monitoring:
• For the older adult with DM, a schedule
for self-monitoring of blood glucose should
be considered, depending on the
individual's functional and cognitive
abilities. The schedule should be based on
the goals of care, target A1C levels, the
potential for modifying therapy, and the
individual's risk for 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
medications
• Consider drug-drug interactions carefully
as most older adult patients are on
multiple drugs as well as supplements.
• Do not assume that because the creatinine is normal that
kidney function is normal, since an older adult with
decreased muscle mass can have normal creatinine
levels with significant renal dysfunction as seen by low
glomerular filtration rate (GFR).
• Monitor liver and kidney function tests periodically even
though diabetes medications, alone or in combination,
are safe in older adult patients when selected carefully.
• In general, a creatinine clearance
estimated at < 60 ml/min warrants dose
adjustments of most renally cleared
medications. In an older woman (68
years) weighing 60 Kg with a serum
creatinine of 1.0, this would translate to
an estimated creatinine clearance of 51
ml/min, just under this threshold.
Medications:
• 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
• o Use with caution in the older adult with diabetes because of an increased
risk of lactic acidosis in patients with impaired renal function.
• o Measure serum creatinine and liver function tests (LFTs) periodically in
the older individual who receives metformin, and with any increase in dose.
• o Measure creatinine clearance with a timed urine collection at least
annually and with increases in dosage of metformin in frail older adults, or
those with decreased muscle mass.
• o Avoid initiating in patients ≥ 80 years of age unless creatinine clearance is
within normal limits.
.
• Thiazolidinediones (TZDs
o TZDs are well tolerated by older adults as they do not
cause hypoglycemia. Side effects of fluid retention and
leg edema can be limiting factors in using this class of
medications in the older adult.
o TZDs should be avoided in patients with Class III and
Class IV congestive heart failure.
• Alpha-Glucosidase Inhibitors:
o Alpha-glucosidase inhibitors are less effective than other agents
and may cause gastrointestinal side effects.
•
• Insulin:
• Elderly subjects often make errors when
trying to mix insulin on their own. The
accuracy of insulin injections has been
shown to be improved in older patients
when they are treated with premixed
insulin.
• In these situations, it is beneficial to use
simpler insulin regimens with fewer daily
injections, such as pre-mixed insulin
preparations, pre-measured doses, and
easier injection systems (e.g., insulin 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.
•
Hypoglycemia:
• Older adult patients commonly exhibit neuroglycopenic
manifestations of hypoglycemia that include
confusion,
delirium, dizziness, weakness or falls as compared to
adrenergic symptoms. It is important that older adult
patients and their caregivers recognize these
symptoms as hypoglycemia and treat appropriately.
• Frail older adult patients may have poor outcomes
from even mild hypoglycemia. For example, injurious
falls can lead to unintended consequences such as
institutionalization. In addition, hypoglycemia can
exacerbate existing conditions (e.g., coronary artery
disease or cerebrovascular disease).
• The older adult with DM who is on an ACE
inhibitor or ARB should have renal
function and serum potassium levels
monitored within 1 to 2 weeks of initiation
of therapy, with each dose increase, and
at least yearly.
• The older adult with DM who is prescribed
a thiazide or loop diuretic should have
electrolytes checked within 1 to 2 weeks
of initiation of therapy or of an increase in
dosage and at least yearly.
Management of Hyperlipidemia
• The targets of therapy, interval of lipid profile screening, and choice
of medications for treatment of hyperlipidemia in older adult
patients with diabetes are the same as those in younger adults.
• 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
less, relaxation of the goals of therapy may be made.
Eye and Foot Care:
• Recommendations for eye and foot
examinations and treatment in older
adults with diabetes are the same as
those for younger individuals. Older
adults may require additional
education and devices such as
mirrors to examine their feet due to
decreased mobility and dexterity.
Nutrition:
• The current trend is to distribute the patient’s
carbohydrate intake as evenly as possible
throughout the day. Education regarding the
importance of consistency in carbohydrate
intake and the timing of meals can help avoid
large fluctuations in blood glucose levels.
• Every effort should be made to minimize the complexity
of meal planning and to engage the spouse, or others
living with the patient, in creating a home environment
that supports positive lifestyle change.
• In chronic care settings, there is no need for a rigid and
restrictive meal plan. A regular diet with consistent,
moderate carbohydrate intake may be sufficient and
may help to avoid under nutrition.
Physical Activity:
• Types of physical activities that may be appropriate
for the older adult include:
o Walking
o Swimming or water aerobics
o Bicycle riding
o Yoga
o Gardening
o Household chores