finding the sweet spot: dm ii treatment in post acute rehabilitation (& a few crumbs for granny...
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Finding the Sweet Spot:
DM II treatment in post acute rehabilitation
(& a few crumbs for granny –
the key to treating DM II in frail elders)
Belinda Setters, MD, MS, AGSFMarch 6, 2014
Kentucky Cardiopulmonary Rehab Symposium
The Sweet Spot: DM II treatment
update
Disclosures
• Acting Associate Chief of Staff , Geriatrics & Extended Care • Director, Acute Care for Elders & Transitional Care Programs
Robley Rex VAMC, Louisville, Ky
• Associate Clinical ProfessorUniversity of Louisville Depts. of Internal and Family & Geriatric Medicine
No financial (or other) incentives, stock or compensation
The Sweet Spot: DM II treatment
update
Learning Objectives
• Review updated guidelines for DM II treatment
• Identify pitfalls of treatment in post acute (rehabilitation) care
• Understand unique features of elderly patients that complicate treatment
• Understand the importance of individualized care
The Sweet Spot: DM II treatment
update
• Just the stats m’am. . .
• 25.8 million diabetics (all ages) = 8.3% of population• > 65 yo, increases to 27% of population (10.9 million)
o 7 million undx patients
• DM II associated with 2 x higher disability
• 42% of persons > 65 yo have at least one disability o = 14 million people
American Diabetes Association: www.diabetes.org CDC: www.cdc.org/diabetes NIH: www.ndep.nih.gov/diabetes-facts
The Sweet Spot: DM II treatment
update
The Sweet Spot: DM II treatment
update
From Dr. Samuel E. Dagogo-Jack: http://www.medscape.org/viewarticle/536351
The Sweet Spot: DM II treatment
update
The Sweet Spot: DM II treatment
update
The Sweet Spot: DM II treatment
update
• Treatment goals . . .
• Fasting blood glucose < 140 mg• Hemoglobin A1C < 7
• If can push to get better #s, without side effects (hypoglycemia), then ok to do so in adult patients
• Post acute care (“rehabilitation”) guidelines follow those of non-critical care acute recommendations
J Clin Endocrinol Metab 2012, 97(1):16-38
The Sweet Spot: DM II treatment
update
• Treatment goals . . . Short term concerns
• Minimize adverse effects of high glucose o Wound healing & infection o Confusion/MS change o Fatigue = decr. participation in therapy o Falls
• Minimize HYPOglycemia • Minimize “pill burden” • Transition patient to home
The Sweet Spot: DM II treatment
update
• Treatment goals . . . Options.
Glucose >140
DX: DM II
Current RX
Adjust RX
No DM II
Monitor BS 24-48 hrs
d/c monitoring
( --)
( + )
The Sweet Spot: DM II treatment
update
• Recommended therapy: Insulin
Long Acting Insulin (Daily) Short Acting
Insulin (with Meals)
Intermediate acting (Twice Daily)
OR
The Sweet Spot: DM II treatment
update
• Insulin types
Action Onset Peak Duration Name Brand
Rapid 15 min 1 hr 2-4 hrs GlucineLispro Aspart
ApidraHumalogNovolog
Regular / “short”
30 min 2 hrs 3-6 hrs Lispro RNovolin R
Humalog RNovolgo R
Intermediate 2 -4 hrs 4-12 hours 12-14 hrs NPH Humulin NNovulin N
Long hrs (aprox 6)
None 24 hrs DetemirGlargine
LevemirLantus
The Sweet Spot: DM II treatment
update
• Insulin types . . . . . “the slide”
• Sliding Scale Insulin o Good for short term coverage to adjust long acting insulins o Should not be used as a substitute for long acting or
short/regular insulin regimen.
diabetesmanager.pbworks.com
The Sweet Spot: DM II treatment
update
The Sweet Spot: DM II treatment
update
www.medscape.org
• Oral agents
Class Pharm Limitations Name Brand
Sulfonylureas Stimulates pancreas to
release insulin
HypoglycemiaCV risks
Liver/renal
GlimeprimideGlyburide GlipizideGliclazide
AmarylMicronaseGluctorolDiamicron
Biguanide Reduces glucose
production
Lactic acidosis Metformin Glucophage
Alpha-glucosidase inhibitor
Reduces glucose
absorption
GI side effects / take with
meals
Acarbase
MiglitolVoglibose
Precose, GlucobayGlysetBasen
Thiazolidinedione Reduces insulin
resistance
Edema Heart failure
Wt gain Liver fxn
Rosiglitazone Pioglitazone
AvandiaActos
Prandial glucose regulators
Incr. insulin secretion
Hypoglycemia RepaglinideNateglinide
PrandinStarlix
Incretin mimetics Incr. insulin sensitivity
hypoglycemia,
Fatigue, anorexia
PramlinitideSitagliptinExenatide
SymlinJanuviaByetta
The Sweet Spot: DM II treatment
update
• Nutrition therapy
Rec: “Consistent Carb” diet
+ Education & Accountability
• Exercise Therapy, activities, walking
American Diabetes Association: www.communitydiabetes.org
The Sweet Spot: DM II treatment
update
• Control Vascular Risk Factors
o Tobacco cessation
o Nutrition
o Weight Loss
o HTN management
o HLD management / statins
o Anti-inflammatory therapies
o Mental & physical activity
The Sweet Spot: DM II in elders
• Treatment Considerations
Micro-vascular Injury (in Years)
Macro-vascular Injuries (in Years)
Control of --
Glucose 8 --
Blood Pressure 2-3 3
Cholesterol -- 3-6
(CHF/AGS, presented at AGS Symposium, May 2003)
The Sweet Spot: DM II in elders
The Sweet Spot: DM II treatment
update
• DM in The Elderly: Unique Concerns
o Erratic eating (or dependency on being fed)
o Inability to report symptoms (dementia, vague symptoms)
o Polypharmacy: multiple meds – competition for clearance
o Slowed metabolism / impaired clearance
o Shift in water-fat body content
o Low reserve, can’t respond to hypoglycemia
Med Care 2006 Apr;44(4):373-7 JAMA 2006 Oct 18;296(15):1858-66. J Am Coll Cardiol 2009 Jan 20;53(3):298-304
The Sweet Spot: DM II treatment
updates
• DM in Elders: Frailty
o Loss of functional reserve
o Slowed response to stress / pathologic illness
o Multisystem organ involvement
o Estimated prognosis (life expectancy)1-2 years
Lancet 2013; 381(9868): 752-762. JAGS 2006; 54(6): 991-100. Clin Geriatr Med 2011; 27(1): 1-15.
The Sweet Spot: DM II treatment
updates
• DM in Elders: Frailty
Philosophy, Ethics, and Humanities in Medicine 2009 4:3 doi:10.1186/1747-5341-4-3
The Sweet Spot: DM II in elders
• Treatment Considerations
• Hemoglobin A1C < 7o Mean plasma glucose 154 mg/dl (2-3 months)o Healthy adults with > 10 year life expectancy
• Hemoglobin A1C between 7 – 8.5o Mean plasma glucose 180 mg/dl (2-3 months)o Adults with limited life expectancy, history of severe
hypoglycemia, or advanced micro-vascular or macro-vascular disease
DIABETES CARE, 2013; 36(1): S11-S66
The Sweet Spot: DM II in elders
• Treatment Considerations
• Blood Pressure & Lipid Goals
• Blood pressure < 140/80• LDL < 100 mg/dl or 70 with CVD• HDL > 40 mg/dl• Triglycerides < 150 mg/dl
DIABETES CARE, 2013; 36(1): S11-S66
The Sweet Spot: DM II in elders
• The “Sweet Spot” for Frail Elders
J Am Geriatr Soc 60:1215–1221, 2012.
The Sweet Spot: DM II in elders
• Other thoughts: Hypoglycemia
• 2 episodes = 80% increased risk for Dementia development
• 3 episodes = 94% increased risk for dementia development
The Sweet Spot: DM II in elders
• Other thoughts
• Life Expectancyo Changes w/ comorbidityo Changes w/ frailty
• Goals of Care o Pt Preferences
The Sweet Spot: DM II treatment
update
• Wrap up
• Blood glucose < 140 or Hg A1C < 7
• Control vascular, other risk factors
• Consider QOL, pt preferences/GOC & life expectancy
• For most elders, especially frail elders, A1C = 8 is target
8 at 80 honey!
Belinda.Setters@va.gov Geriatrics & Extended Care
http://vaww.louisville.va.gov/
@BelindaSetters 502-287-5995
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