Diabetes and The Older Patient

Debra L. Bynum, MDDivision of Geriatric Medicine

Objectives

• 1. Review treatment options in caring for older patients with diabetes

• 2. Understand risks of hyperglycemia and hypoglycemia in older patients

• 3. Appreciate importance of cardiovascular risk reduction in older patients with diabetes by treating hypertension and hyperlipidemia

• 4. Gain awareness of association: diabetes, HTN, and vascular risk factors with dementia

• 5. Discuss the Treatment-Risk Paradox and how this applies to medical management in older patients

Outline• Prevalence

• Acute complications

• Treatment options and goals

• Risks of longstanding diabetes

• Reducing cardiovascular events: treating hypertension and dyslipidemia

• Dementia: association with cardiovascular risk factors; ?can we prevent it?

• The Treatment-Risk Paradox: Paper review

Cases

Case Study #1

• 78 y/o nursing home resident presents for evaluation of recurrent severe hypoglycemia. Diagnosed age 65 , treated with sulfonylurea without response, subsequently treated with insulin, currently 70/30 14 u in AM, 10 u QHS. Logs: 4-6 readings/day, ranging from 30’s (usually in afternoon or early AM) to mid 500’s, average 195.

• PE: 61”, 98 lbs, 138/66, 82. Exam unremarkable A1c=8.6%; Creatinine=1.3, TC=150, HDL=70, LDL=70, TG=50

Case 1:

• Does this patient have type 1 diabetes?

Case study #2

• 92 year old woman comes to you on glyburide at 10 mg a day. She, after much discusssion, is unable to check her own glucose. She is very afraid of having a hypoglycemic reaction as she lives alone. Her Hgb A1C is currently 9.8%. She is otherwise healthy, on no other medications, and is completely active and independent.

Case # 2

• What is the goal of treatment in this woman?

• What are the risks and the benefits of “tight” control for this patient?

• What should her goal A1C be?

• Describe some barriers to self monitoring for older patients.

• Is Metformin contraindicated?

Case # 3

• You are following a 75 year old woman in the nursing home who has a severe dementia that is probably mixed alzheimers/vascular type, complicated by diabetes, hypertension and hyperlipidemia.

• PE: weight 95 lbs

Case # 3…

• How tight should control be for this patient? What would be an optimal HgbA1C?

• How should her diet be managed? Is there any evidence for dietary restrictions in this setting?

• What are the risks and benefits of optimizing her blood pressure control?

Case # 4

• A healthy, active, independent 85 year old woman with DM presents to you for care. She is concerned because her sister has a severe dementia. Other than a blood pressure of 170/70, her PE is unremarkable.

Case study 4

• Is her risk of dementia higher with an underlying diagnosis of diabetes?

• What is the significance of isolated systolic hypertension in the elderly? Should this be treated?

• What is the average life expectancy of a healthy 80 –85 year old woman?

Some Numbers…

• Aging of America– Average life expectancy 72-79– At age 65, average life expectancy 82!– At age 85, average life expectancy 90– Fasting growing segment: over 85

• 1.5% population• Almost 5% of population by 2050

• Prevalence of Diabetes

• Prevalence of Cardiovascular disease

• Prevalence of Dementia

Some Numbers…

• Aging of America

• Prevalence of Diabetes– Over 20% those over 65 (NHANES 1994)– Framingham Data: Diabetes or impaired glucose tolerance

(fasting glucose 120-139) in nearly 40% those over 65– Over 65 account for over 40% diabetic population

• Prevalence of Cardiovascular Disease

• Prevalence of Dementia

Some Numbers…• Aging of America• Prevalence of Diabetes

• Prevalence of Cardiovascular Disease– Heart disease and stroke: Leading causes of death – 60% deaths in those over 85 due to CVD– Morbidity: stroke and CHF– CHF: 6% new diagnoses/per year in age over 85

• Prevalence of Dementia

Some Numbers…• Aging of America

• Prevalence of Diabetes

• Prevalence of Cardiovascular Disease

• Prevalence of Dementia– 6-10% those over 65– 30-50% those over 85– Nearly 70% in those over 95– By 2025, expected 2 million centenarians in US!– Leading public health concern as the new chronic disease…

Why does Diabetes increase with Age?• Changes in insulin secretion, action and hepatic

glucose production with aging

• Genetic predisposition

• Medications that may change glucose metabolism (?thiazides?)

• Older patients more likely to be “lean” diabetics: more problem with insulin secretion than insulin sensitivity as seen in obese, middle aged diabetics

• Latent Autoimmune Diabetes of Adults: LADA

What are the risks of Diabetes in the older patient?• Number 1: Cardiovascular disease

• Nephropathy– Increasing importance of ESRD in older patients

• Neuropathy

• Retinopathy

• Problems with Feet

• New directions:– Dementia– Marker of bad outcomes

• Hyperglycemia bad predictor in those admitted with stroke and other acute illnesses

Diagnosis of Diabetes

• ADA criteria are NOT adjusted for age

• FPG >= 126

• Impaired Glucose Tolerance: glucose 100-125

Impaired Glucose Tolerance…

• Occurs in 25% of older patients

• Increases risk for development of diabetes

• Longitudinal study of older patients: those with Impaired Fasting Glucose had slightly increased risk of cognitive impairment and dementia compared to those with normal glucose

• Lifestyle modification can decrease risk of developing diabetes

Short Term Complications

• Hyperglycemia

• Hypoglycemia

Hyperglycemia

• Dehydration– Increased risk in elderly: decreased intake,

decreased thirst mechanism– Falls, confusion

• Visual disturbances– Significant hyperglycemia distorts lens, visual

blurring

• Confusion

Nonketotic Hyperglycemic Hyperosmolar Coma• More common than DKA in older patients

• Higher mortality

• Usually associated with severe dehydration, infection, myocardial event, stroke, acute stress

• Precipitating factors: dementia, decreased access to fluid, decreased thirst mechanism

Hypoglycemia

• Risk factors:– Older patients– Renal insufficiency

• “normal” creatinine means less: glomerular filtration rate is NOT normal in 90 year old woman who weighs 85 lbs with creatinine of 1.1

– Long acting oral agents• Especially in those with renal insufficiency

– Poor nutrition• Decreased muscle mass and poor glycemic reserves

– Alcohol use– CHF– Post hospitalization– Polypharmacy

Pearl

• Calculate GFR in older patients: “normal” creatinine may NOT be normal!!!

Treatment Options

• Individualized

• Weigh risks of hyperglycemia with hypoglycemia

• No data that tight control prevents stroke or cardiovascular events or improves mortality in this age group

• Consider cost of medications, limited coverage

• 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

Treatment Options: Some Comments….

Treatment options overall similar in older patients

Special notes:beware renal functionbeware polypharmacy and risk of drug interactionsbeware risk of interactions with other comorbidities (CHF, dementia)

Treatment Options: Most common…• Sulfonylureas

– Stimulation of insulin secretion

– Increased risk of hypoglycemia in elderly, esp with renal insuff

– Less risk: glipizide (glucotrol), glimepride (amaryl);

– Higher Risk: glyburide (diabeta, micronase)

metformin

• Biguanide• Decrease hepatic glucose production• Low risk for hypoglycemia• Side effects: gi• Risk: lactic acidosis• Not in women with creat over 1.4, men over

1.5, OR creat clearance < 60• NOT absolute contraindication with age, but

beware of renal function

Thiazolidinediones

• Improving insulin sensitivity

• Rosiglitazone (avandia)

• Pioglitazone (actos)

• Do not cause hypoglycemia

• Weight gain, fluid retention

• Contraindicated with severe heart failure

Insulin

• May be best option

• Can the patient do it?– Dementia– Caregiver– Vision– Arthritis

• Likely underutilized due to fear of hypoglycemia…

Glargine (lantus) insulin

• Long acting

• Often fear of hypoglycemia because long acting, especially in patients with renal insufficiency or unreliable po intake

• But studies demonstrating less risk of hypoglycemia, especially in patients with “brittle” diabetes and nocturnal hypoglycemia

Treatment Goals

• Individualized• No data for tight control…• Most recommend Hgb A1c 7-8%• Other options:

– Tight control: healthy “young” older patients (lifespan 20years) to decrease risk nephropathy, retinopathy

– “permissive”: those with advanced illnesses, terminal illnesses; goal more to prevent severe hyperglycemia and avoid hypoglycemia; goal glucoses 200 range

Treatment Goals

• Endocrinology, General Internal Medicine/Family Medicine or Geriatrics?

• Geriatricians see older patients with dementia; Endocrinologists use more complicated regimens and care for slightly younger patients and/or those with microvascular complications

• ALL have lower than advised rates of screening for diabetic complications, adequate treatment of hypertension and hyperlipidemia, and goal AIc–

• is this bad? Don’t know….

Some special circumstances

• Tube feeding– Increases hyperglycemia– Specialized formulas– Acute setting: continuous insulin, BID

NPH, Q6 Reg– Long term: basal insulin with glargine;

with bolus feeds, consider short acting insulin prior to bolus

Special Circumstances…

• Type 1 diabetes– Decreased beta cell function with aging– More common in younger patients but can occur

in older patients (10-15% of elderly patients with diabetes have evidence of autoimmunity)

– “latent autoimmune diabetes of adulthood”– DKA– “brittle” with episodes of hypoglycemia

– First case…

Nursing home setting

• Risk of ulcers (heel and sacral)

• Risk of dehydration

• Little to support dietary restrictions in frail nursing home elders– Quality of life concerns– Risk of malnutrition– Anorexia/depression– Chewing/dental problems

– 2001 study found no difference in glycemic control in patients on restricted diet compared to those on regular diet with more emphasis on pharmacologic control

Nephropathy

• Previously no recommendation to screen for microalbuminuria if normal renal function– Lower risk of ESRD in older patients with DM– Long interval between presence of albumin and

ESRD….

• Current AGS and ADA guidelines recommend annual check for microalbumin– Lifespan of 70 year old is 10 years or more– ESRD increasing prevalence in elderly with more older

patients on dialysis…– Marker of increased stroke and CVD risk in addition to

nephropathy in older patients

Vision…

• Retinopathy– Prevalence in older patients with DM seems to be less

and overall less progressive disease than in younger patients with DM

• Glaucoma– Three times more common in older patients with

diabetes (11% vs 3.8%)

• Cataracts– More common in older patients with DM (38% vs 16%)– Association with more rapidly progressive posterior

capsule cataracts …

Neuropathy

• Very common– Over 50% in those over 80

• Not always due to Diabetes

• 1/3 older patients cannot see/reach feet

• Importance of caregiver education

Special Population: The FRAIL

• Not all older patients are FRAIL

• Frailty as increasingly recognized diagnosis

• Features: – Functional decline– Sarcopenia– Weight loss– Associated diseases such as Diabetes– Stressors that precipitate

• Hip fractures, pneumonia, depression, stroke

Treatment of the Frail

• Care with any dietary restrictions

• Significant number nursing home residents with weight loss, at risk for malnutrition

• Tight control likely not goal

• Still consider treatment of cardiovascular risk factors to reduce risk of CHF, stroke and morbidity

Big Goal: Prevention of Cardiovascular Events…

• Common diseases: Diabetes, Hypertension, Hyperlipidemia

• Common outcomes: Stroke, CHF/CAD, Dementia

• No evidence that aggressive treatment of DM prevents/ changes these outcomes, but DM often seen in patients with HTN and hyperlipidemia, and mounting evidence that treatment of these risk factors can modify the risk of CAD, CHF, stroke and possibly even dementia in this group

Diabetes: CV equivalent

• Patients with type 2 diabetes without prior hx of heart attack have same risk of MI compared to patients with prior hx of MI

• Therefore, treat patients with DM as aggressively as secondary treatment in patients with known CVD

• ?age as new “CV equivalent”

• Bad combination: DM and older age!!!

Hypertension and Hyperlipidemia

• Treatment of hypertension and hyperlipidemia reduces CV outcomes

• Biggest bang for the buck: treating in High Risk Groups

• Higher benefits in those with diabetes and advanced age

Hypertension• Hypertension is very common in older

patients, mainly due to Systolic Hypertension (SH)

– Hypertension seen in 60% those over 65– 75% hypertension in older patients =SH– JNC definition: SBP >160, DBP <90– Pulse Pressure: SBP – DBP

• Higher (over 50) due to stiff arteries • SBP and PP MORE predictive of stroke and CV

events in older patients

Hypertension

• Multiple large randomized controlled trials have demonstrated significant benefit in treating Systolic Hypertension in older patients– SHEP– SYST-EUR– SYST-CHINA– SCOPE

Systolic Hypertension

• Treatment of SH in older patients:

– Decreased risk of stroke

– Decreased risk of CHF

– Decreased combined endpoint of all CV events (CHF, stroke, CAD, mortality)

– Larger benefits seen in patients with diabetes…

Treatment of Hypertension

• Choice of agents:

– Thiazide diuretics (HCTZ, maxzide)ALLHAT study: JUST AS EFFECTIVE AS THE MORE EXPENSIVE, NEWER MEDICATIONS!

– ACE inhibitors, angiotensin II receptor blockers, long acting calcium channel blockers

– Beta blockers

Systolic Hypertension and Dementia…• Epidemiological studies :association between

SH and dementia in older patients

• Surprise finding in SH trials

– Patients in treatment arms of trials had reduced risk of dementia at follow up (4 years) compared to those in placebo group

– Two surprises:• Those in placebo group, even after trial ended and started on

antihypertensive treatment, STILL had increased risk of dementia

• Risk of Vascular AND Alzheimer dementias were increased!

Dementia• Systolic Hypertension and Diabetes seem

to be independent risk factors for dementia

– Vascular dementia and alzheimer type

– SH, DM, and dementia all more common with aging: a difficult web to untangle…

– But dementia seems to be related to or worsened by traditional cardiovascular risk factors…

Treatment of SH: Summary• Treatment of SH in older patients decreases the risk of

stroke, CHF, and combined CV events

• Evidence that treatment of SH prevents dementia…

• Aging, HTN and DM HUGE risk for CVD

• Treatment of CVD risk factors such as HTN critical treatment of older patients with DM

• Thiazide diuretics cheap and effective in older patients

• Multiple therapeutic options

Hyperlipidemia• Previously many older patients not treated

– Thought that statin agents took years to have effect, and those over age 70 would not benefit

– Often cited “lack of data” in older group – Worry about increased risks

• But…– Newer evidence that statin agents work short term– Newer thoughts about average lifespans…– Lack of data due to prior studies excluding older

patients, not due to lack of observed benefit in trials…– So far, increased risks of rhabdo and liver disease have

not really panned out in older patients

Hyperlipidemia

• More studies now addressing treatment of hyperlipidemia in older patients

• CARE trial: diabetic patients with LDL <130 benefited from statin agents to further reduce cholesterol, regardless of age

• PROSPER study (Lancet 2002): Pravastatin given for 3 years reduced CVD risk in elderly

• Heart Protection Study: those over 75-80 had a GREATER reduction in cardiovascular events (29%) compared to the younger patients in the trial (25%)

Summary of studies…

Hyperlipidemia• Given fact that older patients have much

higher risk of CV events, then the same relative risk reduction by treating this group may have overall GREATER absolute risk reduction

The Treatment Paradox

• BUT, is this group at increased risk for complications?

– The treatment paradox… to be discussed

Hyperlipidemia

• Treatment groups:

– Older patients with DM

– Older patients with prior CV event (stroke, MI, CHF)

– All older patients with hyperlipidemia?

• Patients over age 70 should be considered very likely to have underlying CAD/CVD (much as those with diabetes): the new Cardiovascular equivalent

Treatment of Hyperlipidemia: summary• Aging as a “cardiovascular” equivalent; Aging and DM as

major risk factors for CVD

• Treatment of hyperlipidemia in older patients is well tolerated

• Treatment of hyperlipidemia in older patients has similar/better reductions in CV events as in younger patients

• Given the increased risk of CV events in this group, the potential benefit may be greater

• Benefit may be in reduction of CV events, CHF, stroke, and possible dementia; mortality benefit not clear

Further Management…

• Smoking cessation

• Weight loss

• Dietary changes

• Exercise

• Daily ASA

Summary Guidelines for care of older persons with Diabetes: AGS 2003Aspirin Recommended if no other anticoagulant and

no contraindications

Smoking cessation Recommended

Hypertension Target <140/80 (<130/80) as tolerated

Lipids LDL <100

Control A1c <7% in healthy with good functional status; <8% in frail elders with life expectancy <5 yr or when risks of tight control outweigh benefits

Monitoring A1c every 6 mo if not at goal; every year if at goal; create individual plan for self monitoring

Hypoglycemia Referral, contacts

Dilated eye exam Time of dx and annually for those at risk, every 2 yr for those at low risk

Foot care Annual screening

Microalbumin Dx and annually

Screening Depression, cognitive impairment, falls, pain, urinary incontinence, polypharmacy

Summary Points

• Not clear that tight control of glucose is of great benefit in older patients

• Diagnosis and treatment options are not really different

• Avoidance of hypoglycemia and severe hyperglycemia are important

• Care in older patients must include consideration of Functional Status– Cognition– Physical ability (vision, arthritis)– Social support– Financial support

Summary Points…• DM and HTN are traditional risk factors for CVD

• Aging, like DM, as “cardiovascular equivalent”, older patients have HIGH risk of underlying CVD

• Older patients with DM and HTN die of CVD and suffer morbidity from strokes and CHF

• Dementia is probably related to underlying CV risk factors, with an increased prevalence in those who – are older– Have diabetes– Have SH

• Treatment of CV risk factors may decrease the risk of dementia

The Treatment-Risk Paradox

• What is it?

• Why is this important in the care of older patients?

• Why might older patients be “undertreated”?

• What types of processes might older patients be “undertreated”

• Review of the Article: Lipid Lowering Therapy With Statins in High Risk Elderly Patients; JAMA 2004; 291 (15) 1864-1870.

Paper: Background

• Multiple studies have shown inverse relationship between treatment (variety of illnesses) and age, even when evidence supports use in older patients

• Concerns about quality of life, treatment complications, interactions with other medications or comorbidities

• We are taught the key to geriatrics: start low and go slow….

But…

• Not all older patients are the same

• Age is more than number; physiological age may be important

• Recognition of difference between life expectancy at given age and average life expectancy at birth…

• Recognition that “Frail” patient is different than the “robust” patient, regardless of age…

Study Design

• Retrospective cohort study

• Databases of over 1 million elderly in Ontario, study looked at nearly 400,000 over age 66 with history of CV disease or DM (SECONDARY PREVENTION)

• Outcome: likelihood of statin use for each CV risk group

?Confounders?

• What are the potential “confounders” for this type of study (what other reasons other than age might account for a difference in statin use….)?

Adjustments

• Adjusted for:– Age– Sex– Socioeconomic status– Rural or urban residence

Results

• Only 19% prescribed statins

• Likelihood of statin prescription was 6.4% lower for each year of increased age AND each 1% increase in predicted 3 year mortality risk

Likelihood of statin prescription: Ages 66-74

Low CV risk

(7.8% 3 year mortality)

Intermediate Baseline Risk

(12.8% 3 year mortality)

High Baseline Risk

(34.4 % 3 year mortality)

37.7% 26.7% 23.4%

Likelihood of statin Rx: ages 75-80

Low CV risk

(13.7% 3 year mortality)

Intermediate risk

(21% 3 year mortality)

High risk

(43% 3 year mortality)

29% 19% 15%

Likelihood of statin Rx: age > 80

Low risk

(25% 3 year mortality)

Intermediate risk

( 40% mortality)

High risk

(60 % 3 year mortality)

13% 6% 4%

Results

• Patients prescribed statins: more likely younger, men, history of angina/acute MI/invasive cardiac procedure

• Patients not prescribed statins: more likely to have DM, CHF, stroke and to live in rural areas

• Lower use of statins in patients with higher CV risk across full spectrum of CV risk and across entire spectrum of age

Discussion:

• How to interpret these results?

• Caution?

• What is the risk of “undertreatment”? “overtreatment”?