Type 2 Diabetes & The Older

Adult

Denise Soltow Hershey PhD, FNP-BCAssociate Professor

College of Nursing, Michigan State University

Objectives Identify risk factors that can lead to hypoglycemia

Develop and understanding of the diagnostic criteria and glycemic targets for older adults

Gain knowledge regarding medication management, including deintensification, simplification and deprescribing in older adults

Gain knowledge regarding management of diabetes at end of life.

Background

Diabetes is defined as:

FPG ≥ 126 mg/dl or A1c ≥ 6.5

Diabetes classified as either Type 1 (T1D) or Type 2 (T2D)

T1D – more likely to occur in younger adults

T2D occurs in 9% of adults

T2D occurs in 20 % of adults 65 y/o or older; accounts for 90 –95% of all diabetes cases in older adults.

Aging and T2D increases risk for:

Functional decline and disability

Development of frailty & muscle loss

Falls

Lower quality of life

Untreated T2D leads to the development of micro and macro vascular complications

Risk factors Genetic• Family history

• parent or sibling• Race

• Black, Hispanic/Latino, American Indian, Alaska Native and Asian-American, Native Hawaiian or Pacific Islander

Lifestyle• Inactivity• Diet

Comorbidities• Overweight or Obese

• Fat distribution• High Blood Pressure• Low HDL or high Triglycerides• History of heart Disease or stroke• Depression• Polycystic Ovary Syndrome

Aging• Decrease in exercise – loss of muscle mass - weight gain with age

Pathophysiology

Presentation in older adults

Different than younger adults

Older adults more likely to present with

Dehydration

Confusion

Incontinence

Diabetes complications

Neuropathy

Nephropathy

ADA Diagnostic Criteria for Prediabetes and Diabetes

Diagnostic Test

Pre-diabetes

Diabetes

OGTT 2-hour post

140 – 199 mg/dl

≥ 200mg/dl

Fasting Plasma Glucose

100 - 125 mg/dl

≥ 126 mg/dl

A1c 5.7 – 6.4 % ≥ 6.5%

Treatment Goals

ADA Framework for considering treatment goals for glycemia, blood pressure and dyslipidemia in older adults with diabetes ( 2019)

Patient Characteristics/Health Status

Rationale A1c Goal

Blood pressure Lipids

Healthy (few coexisting chronic conditions, intact cognitive and functional status)

Longer remaining life expectancy

< 7.5% <140/90 mmHg Statin unless contraindicated or not tolerated

Complex/Intermediate (multiple coexisting comorbidities or 2+ instrumental ADL Impairments, or mild to moderate cognitive impairment)

Intermediate remaining life expectancy, high treatment burden, hypoglycemia vulnerability, fall risk

<8.0% < 140/90 mmHg Statin unless contraindicated or not tolerated

Very complex/poor health (LTC or end-stage chronic illnesses, or moderate to severe cognitive impairment or 2+ ADL dependencies)

Limited remaining life expectancy makes benefit uncertain

<8.5% <150/90 mmHg Consider likelihood of benefit with statin

Management Considerations

Individualization is essential

• functional status, • risk for hypoglycemia• prevention of hospital admissions • Maintenance and/or improvement of functional

status

Goals based on:

• Hypertension• Hyperlipidemia• Obesity

Prevention of management of comorbidities

Prevention of Hypoglycemia

Hypoglycemia Increases risk for

Heart Failure

Dementia

Myocardial infarction

Stroke

Falls

Fractures

Death

Risk Factors for Hypoglycemia

Medications used in the treatment of T2D

Psychosocial factorsLiving aloneReduced food intake Depression

Cognitive issues memory loss and dementia

Sensory changes Hearing loss Visual impairmentDiminished taste

Motor changesDecreased dexterityReduced physical activityImpaired mobility

Comorbidities

Decreased Renal and hepatic function

Overall decreased awareness of symptoms associated with hypoglycemia

Medication selection

Metformin 1st line for those without contraindication

Selection of 2nd agent and insulin is dependent upon

patient’s health status and risk for hypoglycemia

Not uncommon for older adults to be on 2 – 3 agents.

If on sulfonylurea when insulin is introduced – sulfonylurea

needs to be tapered and discontinued.

BiguanidesMetformin

Usual dose is 850 – 1000mg Bid po

1 – 2 % A1c reduction

GI effects are common – can be dose related

Considerations in older adults:• Recommended initial therapy• Low risk for hypoglycemia• Reduce cardiovascular events and mortality• Do not use if eGFR< 30.• Avoid in patients with decompensated HF

SulfonylureasGlyburide, Glipizide, Glimepiride

PO daily med, dose dependent on specific agent

1 – 2% A1c reduction

Adverse events• Risk for hypoglycemia,• weight gain • increased risk of CV mortality

Use with caution• Glyburide is not recommended in older adults• Glipizide and Glimepiride needs to be used very cautiously

Thiazolidinediones Pioglitazone & Rosiglitazone

Daily, oral

Dose dependent on agent

1 – 2% reduction in A1C

Adverse effects:• Fluid retention• Weight gain• Fracture risk• Bladder cancer (pioglitazone)• Increased LDL (rosiglitazone)• Increased risk for MI ( rosiglitazone)

Considerations in older adults• Do no use in patients with renal impairment• Use cautiously in hepatic insufficiency, HF and CAD• Avoid in patients who are a fall risk or at high risk for fractures

Α-Glucosidase inhibitors

Arcarbose

50 – 100mg TID po

A1c reduction 0.4% - 0.9%

Side effects:• Flatulence• Diarrhea• Abdominal pain

Considerations for older adults:• CV events decreased in patients with impaired

glucose tolerance• Do not use in patients with comorbid liver or

bowel disease or if serum creatine > 2 mg/dl

Melitnides Repaglinide, Nateglinide

Dose dependent on regimen, administered TID orally

0.4% - 0.9% A1c reduction

Adverse events:• Weight gain• Peripheral edema• Hepatotoxicity• GI disturbances• Risk of hypoglycemia

Considerations for Older Adults• CV events decreased in patients with impaired glucose

tolerance• Do no use in patients with comorbid liver or bowel disease or if

serum creatinine > 2 mg/dl

Amylin mimetics

Pramlintide

120 μg before meals, sub-q

Adverse Events:• N/V• Risk hypoglycemia when used with insulin

Considerations for older adults• Should not be used in patients with an A1c >

9%• Avoid use in patients with decreased

hypoglycemia awareness• Avoid in patients with history of poor

adherence

GLP-1 receptor agonist

Exenatide, Liraglutide, Lixisenatide

Dose dependent on modality, sub-q

A1c reduction 1 – 1.5%

• Weight loss• N/V/D• Risk for acute pancreatitis• Injection site reactions• Increased risk of hypoglycemia when taking sulfonylureas

Adverse events:

• Increased risk of side effects in patients with renal insufficiency• Exenatide not indicated with eGFR < 30• Caution when using lixisenatide• Liraglutide may provide some CV benefits• Good motor skills and visual acuity needed due to being an

injectable

Considerations in older adults

DPP-4 inhibitors Sitagliptin, Saxagliptin, Linagliptin, Alogliptin,

Dose dependent on regimen, Oral daily

A1c reduction: 0.5 - 0.8%

Adverse effects:• Join pain• Skin lesions• Potentials risk of acute pancreatitis

Considerations for use in older adults• Can be used in renal impairment• Renal dose adjustment required for linagliptin

SGLT2 inhibitors

Dapglifozin, Canagliflozin, Empaglifozin

Dose dependent on modality, daily, po

A1c reduction .5% - .7%

• Weight loss• Blood pressure lowering• Vulvovaginal candidiasis• Urinary tract infection• Risk of euglycemic diabetic ketoacidosis• Risk of amputation and fractures with canagliflozin• Increased LDL cholesterol

Adverse effects:

• May lead to abnormalities in renal function• Avoid in older patients with preexisting renal impairment• Avoid when eGFR <60

Considerations for older adults

Insulin Novolog, Humalog

Individualized, sub-q

A1c reduction – no limit

Adverse events• Hypoglycemia• Weight gain

Considerations for use in older adults• Dosing errors can occur with functional and

cognitive changes in older adults• Can challenge self-management capacity• Lower dose may be required in patients with

lower eGFR

Management of Comorbidities

•Minimizes both macrovascular and microvascular complications

Effective diabetes management also

includes management of lipids and blood pressure

•Important in order to decrease risk of frailty and functional status

Nutritional status assessment

•90% of T2D patients are obese•Weight loss in fit older patients can be beneficialObesity –

•Target systolic of 140 or less should be goal•Systolic less than 130 has shown few benefits, increases risk of falls, cognitive decline and frailty.

•Frail individuals BP target should be 145 –160/90

HTN

•Managed until the age of 80, some studies show benefit until age 85

•Statins are recommended class of medications•Statins should be stopped in older adults with severe morbidity and/or limited life expectancy

•Fibrates can be used in healthy adults, no recommended in frail older adults

Hyperlipidemia

Inappropriate Polypharmacy

T2D puts older adults at risk for inappropriate polypharmacy

The use of multi antidiabetic meds and medications for other comorbidities increases risk

Need to consider if intensifying treatment is necessary

Questions to be asked:

Can other medications be reduced or eliminated as new medications are added?

What adverse effects need to be considered? (hypoglycemia, weight gain etc)

Will some of these effects be increased by the addition of new medication?

What are the patient preferences?

What is the patients and care givers capacity? Are they capable to follow the plan and monitor for side effects?

May need to consider either simplification and/or deintensification of regimen.

Deintensification – Deprescribing

Patient health status Simplification Deintensification/deprescribing

Healthy (few comorbidities, functional & cognitive status intact)

• Severe or recurrent hypoglycemia (if on insulin)

• Wide glucose excursions• Decline in cognitive or functional

status

• Severe or recurrent hypoglycemia on non-insulin therapy

• Wide glucose excursions• Inappropriate polypharmacy is

present

Complex/Intermediate(multiple comorbidities, 2+ instrumental ADL impairment or mild to moderate cognitive impairment)

• Severe or recurrent hypoglycemia (if on insulin)

• Unable to manage complexity of insulin regimen

• Significant change in social circumstances (loss of caregiver, financial difficulties, change in living situation)

• Severe or recurrent hypoglycemia on non-insulin therapy

• Wide glucose excursions• Inappropriate polypharmacy is

present

Community-dwelling(receiving care in a skilled nursing facility for short-term (ST) rehab)

• If treatment regimen was escalated during recent hospitalization, the reinstating of prehospital regimen is appropriate during rehab

• If hospitalization resulted in weight loss, anorexia, ST cognitive decline and/or loss of physical functioning

Very complex/poor health(long-term (LT) care, end stage chronic disease, moderate to severe cognitive impairment or 2 + ADL dependencies)

• On Insulin and patient desires to decrease number of injections and finger sticks

• inconsistent eating pattern

• On hypoglycemic agents with high risk of hypoglycemic events

• Taking medications without clear benefit

EOL • Pain or discomfort caused by treatment

• Excessive caregiver stress due to treatment complexity

• Taking medications that do not have any clear benefit of improving symptoms &/or comfort

ADA 2019 recommendations for deintensification and simplification of treatment regimens in older adults with T2D

Management at End of Life

Goal

Decreasing symptomsImprove comfort

Prevention of hypoglycemic and hyperosmolar hyperglycemic events

(polydipsia and polyuria)

Discussions regarding diabetes

Focus on frequency of glucose testingContinuation or stoppage of medications

Monitoring of glycemic control

EOL Management Changes

Weeks to monthsMaintain glucose levels between 180

and 360 mg/dlTarget levels based on patient’s

preferences and risk for development of hyperosmolar hyperglycemic

eventsRequirements for self blood glucose

monitoring reduced from daily to every 3 days

A1c’s no longer requiredMedications may need to be adjusted based on patients' symptoms and risk

for hyperosmolar events

Days to liveMain goal prevention of hypoglycemia

Oral medications can be stoppedGlucose monitoring only when

patients are exhibiting symptoms of hypo or hyperglycemia

Short acting insulin is appropriate in patients who are conscious and

experiencing hyperglycemic events.

Conclusions: Implications for Practice

Management plans take into consideration:

Patients functional and cognitive status Mutual preferences and values

Are collaboratively developed and include shared decision making and mutual goal

setting

Goals need to consider

Current functional statusPrevention of hypoglycemia

Prevention of unnecessary hospital admissions

Focus on improving functional healthReduction of disability

Adjusted as patient moves across the aging trajectory

Questions

References

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